This is the journey level of the series. Positions work under general supervision and perform medical analysis, assist in the development of policies, program evaluation, contract administration, and/or perform coding compliance audits. Positions provide consultative services to medical providers and/or staff regarding health care policy or cost containment programs.

Confers with department staff in the development and implementation of program and procedural changes to assure compliance with department requirements, rules and regulations; 

Takes full responsibility in conducting in-depth analysis of health care cost issues and programs by aiding in the preparation of project plans, conducting or leading data-gathering operations, analyzing data, reporting specific findings; develops, implements, and prepares project reports for written and/or oral presentation;   

Provides technical and consultative assistance to medical providers and/or department staff regarding health care programs; develops and provides training for the medical provider community and other staff of policy and program changes;  

Analyzes and evaluates proposed legislation and program and policy changes to ascertain administrative feasibility;   

Prepares and conducts economic feasibility studies relating to health care best practices, quality, and/or costs;   

Assists in the design of complex reporting systems; checks reporting procedures to ensure validity; 

Compiles technical information and writes analyses, summaries, histories, and briefs;  

Develops, interprets, and implements changes to medical program policies;  

Promulgates administrative and procedural regulations for program implementation; 

Monitors program policies and procedures for adequacy and consistency, making recommendations in order to improve effectiveness of program; 

Provides liaison and coordination between medical providers and department staff; 

Performs compliance audits of healthcare provider bills received to ensure the provider’s compliance with the Medical Aid Rules, Fee Schedules and procedural coding guidelines; 

Provides consultative services to department staff and medical providers regarding program administration and policies; 

Participates in the decision-making process and coordinates implementation of program changes from project recommendations; 

Coordinates and consults with department staff regarding implementation, monitoring, and follow-up on project recommendations;  

Provides technical assistance; 

Assists in the review and analysis of ICD & CPT coding, and in developing and implementing educational campaigns and targeted consultation and outreach to medical providers regarding expectations for diagnosis coding; 

Gathers data to identify trends; reports on findings of data; coaches and mentors staff within unit and agency on improvements in the quality and timeliness of diagnosis coding;  

Educates internal and external stakeholders on how diagnostic and procedural codes impact reimbursement; 

May be a lead worker;  

Performs other work as required. 

Knowledge of:  state policies and regulations related to health care programs; principles and practices of program planning and evaluation; current trends and economic problems relating to health care cost and the injured worker; health care organizations and industry; the legislative process. 

Ability to:  develop and evaluate programs; work effectively with program staff, medical providers, and other affected parties; analyze, interpret and resolve complex problems related to health care cost programs; communicate clearly and effectively both orally and in written form.

There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.

Persons legally authorized to work in the U.S. under federal law, including Deferred Action for Childhood Arrivals recipients, are eligible for employment unless prohibited by other state or federal law.

A Bachelor’s degree with major study in public health, public administration, nursing, health care administration, economics, business administration, or closely allied field.  

AND 

At least one year of consultative experience in the research and analysis of health services program. 

Two additional years of qualifying experience may be substituted for the Bachelor’s degree.

For positions leading staff performing medical coding work, a Certified Professional Coder (CPC) certification, or equivalent, may be required.

New class Effective July 15, 1988
Revised definition March 14, 1989
Revised definition and title change (formerly Medical Program Specialist 1, L&I) September 18, 1989
New class code: (formerly 54950) effective July 1, 2007
Revise class. Added class series concept, revised definition, typical work, desirable qualifications, adopted June 13, 2019, effective July 1, 2019.
Revise class series concept: adopted May 14, 2020, effective May 15, 2020.

Revised Legal Requirements; effective June 6, 2024, due to adopted legislative action.