State of Maryland

A Medical Care Program Specialist II is the full performance level of work developing recommendations and implementing medical care program policies and regulations that impact one or more specific Medical Care Programs for the Maryland Department of Health (MDH).  Employees in this classification do not supervise.

Employees in this classification receive general supervision from a Medical Care Program Supervisor or Medical Care Program Manager or a health care professional.

Positions in this classification are evaluated by using the classification job evaluation methodology.  The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of the class specification.

The Medical Care Program Specialist Trainee, Medical Care Program Specialist I and Medical Care Program Specialist II are differentiated on the basis of degree of supervisory control exercised by the supervisor.  The Medical Care Program Specialist Trainee learns to perform duties under close supervision.  The Medical Care Program Specialist I performs duties under close supervision at times and under general supervision at other times depending upon the complexity of the specific duty being performed.  The Medical Care Program Specialist II performs the full range of duties and responsibilities under general supervision. The Medical Care Program Specialist II is differentiated from the Medical Care Program Supervisor in that the Medical Care Program Supervisor has supervisory responsibility for lower-level Medical Care Program Specialist and is responsible for supervising a section of health care professionals, paraprofessionals and clerical employees.

Develops recommendations and implements Medical Care Program policies and regulations;

Conducts program specific studies and surveys and prepares reports related to Medical Care Program services;

Identifies discrepancies in case management, billing, pricing, and payment records for Medical Care Program services and makes recommendations for corrective actions;

Interprets and applies Medical Care Program policies and regulations;

Makes recommendations for implementing changes to Medical Care Program services;

Acts as a liaison with public and private agencies regarding Medical Care Program services;

Consults with service providers, recipients, and their families and representatives regarding benefits and claims issues for Medical Care Programs;

Provides consultation and assistance to public and private agencies regarding Medical Care Program Services;

Develops and participates in training programs concerning Medical Care Program services;

Examines the use of Medical Care Program services for evidence of abuse;

Identifies methods for cost avoidance when payments for Medical Care Program services are available from other sources;

Participates in audits, inspections, investigations and utilization review of Medical Care Program services for quality assurance;

Makes recommendations on unusual situations regarding policy interpretation;

May testify at administrative appeals or hearings;

May provide guidance for other personnel and support staff;

Performs other related duties.

Knowledge of Medical Care Program eligibility, criteria, policies and regulations;

Knowledge of utilization review and control techniques;

Knowledge of Medical Care Program claims adjudication operations, audit principles, recipient needs, management information systems and third-party liability issues;

Knowledge of individual providers, agencies, facilities and community organizations providing services to Medical Care Program recipients;

Ability to conduct and participate in research programs, studies and surveys;

Ability to present concepts and plans to public and professional groups;

Ability to prepare reports outlining program accomplishments;

Ability to establish and maintain working relationships with medical and allied professionals, volunteer and civic organizations, individuals and staff;

Ability to communicate effectively with employees, volunteers, supervisors, volunteer and civic organizations and the general public.

Experience: Seven years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs.

Notes:

1. Candidates may substitute the possession of a Bachelor's degree from an accredited college or university and three years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs for the required experience.

2. Candidates may substitute the possession of a Master’s degree from an accredited college or university in the related field of work for the required experience.

3. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer in Operational Analysis classifications or Health Services Management specialty codes in the health-related field of work on a year-for-year basis for the required experience.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department or agency specifically address the essential job functions of each position.

This is a Skilled Service classification in the State Personnel Management System.  All positions in this classification are Skilled Service positions.  Some positions in Skilled Service classifications may be designated Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is assigned to Bargaining Unit E, Health Care Professional classes.  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial and confidential employees are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.  Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.

This classification is one level in a Non-Competitive Promotion (NCP) series.  NCP promotions are promotions by which employees may advance in grade and class level from trainee to full performance levels in a classification series.  In order to be non-competitively promoted to the next level in a NCP series, an employee must: 1) perform the main purpose of the class as defined in the Nature of Work section of the class specification; 2) receive the type of supervision defined in the class specification, and 3) meet the minimum specifications of the classification.