State of Maryland

A Medical Care Program Associate Lead/Advanced is the lead or advanced level of work in a Medical Assistance Program in the Maryland Department of Health (MDH).  Employees in this classification apply, interpret and process program specific information, policies, regulations and guidelines in a variety of program related activities.  Employees in this classification that function as lead workers assign, review and approve the work of and train lower-level Medical Care Program Associates and may oversee the work of clerical support staff.  Employees in this classification that function as advanced workers are assigned appeals cases and are responsible for conducting, pre-hearing conferences, providing testimony at administrative hearings and ensuring compliance to decisions rendered in hearings.  Employees in this classification do not supervise other Medical Care Program Associates.

Employees in this classification receive general supervision from a Medical Care Program Associate Supervisor, a Medical Care Program Specialist or a Medical Care Program Supervisor.

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 Associate Lead/Advanced is differentiated from the Medical Care Program Associate II in that the Medical Care Program Associate Lead/Advanced either assigns, reviews and approves the work of and trains lower-level Medical Care Program Associates or performs advanced duties in handling appeals cases while the Medical Care Program Associate II performs the full range of duties and responsibilities under general supervision.  The Medical Care Program Associate Lead/Advanced is differentiated from the Medical Care Program Associate Supervisor in that the Medical Care Program Associate Supervisor has supervisory responsibility for lower-level Medical Care Program Associates.

                    When assigned as a Medical Care Program Associate Lead:

Assigns, reviews and approves the work of lower-level Medical Care Program Associates;

Trains lower-level Medical Care Program Associates;

Makes recommendations to improve or modify operating procedures and internal controls;

May work in the Appeals Unit and schedule and attends hearings and maintain Appeals Tracking logs;

Provides advice and guidance to lower-level Medical Care Program Associates on the resolution of complex problems in reviewing and verifying medical assistance data (claims forms, encounter data, enrollment forms, adjustment forms, insurance data, or other related documents) for accuracy, completeness and compliance with State and federal regulations;

Secures or obtains missing data by calling or writing involved parties and completing appropriate forms;

Reviews and determines appropriate Medical Assistance eligibility using State and federal computer information systems;

Contacts insurance companies, health care providers, other governmental agencies and recipients in order to verify information submitted to the Medical Care Program for payment or review;

Responds to inquiries and complaints and provides liaison services to health care providers, insurance companies, other governmental agencies and recipients;

Refers applicants to support services as appropriate;

Determines continued eligibility for medical assistance;

Prepares and reviews required reports and maintains a client/provider tracking system;

Enters and codes data into automated information systems;

May oversee the work of clerical support staff;

Performs other related duties.              

                  When assigned as a Medical Care Program Associate Advanced:            

Reviews case records for accuracy of Medical eligibility decisions and calculations;

Provides appellant with summary and other documents prior to a hearing;

Conducts pre-hearing conferences to resolve appeal issues prior to hearings;

Testifies and presents MDH's position and decisions in administrative hearings;

Ensures compliance with decisions rendered in administrative hearings by reviewing records and case files, preparing reports, and completing and mailing appropriate forms and notices;

Provides advice and guidance to lower-level Medical Care Program Associates on the resolution of complex problems in reviewing and verifying medical assistance data (claims forms, encounter data, enrollment forms, adjustment forms, insurance data, or other related documents) for accuracy, completeness and compliance with State and federal regulations;

Secures or obtains missing data by calling or writing involved parties and completing appropriate forms;

Reviews and determines appropriate Medical Assistance eligibility using State and federal computer information systems;

Contacts insurance companies, health care providers, other governmental agencies and recipients in order to verify information submitted to the Medical Care Program for payment or review;

Responds to inquiries and complaints and provides liaison services to health care providers, insurance companies, other governmental agencies and recipients;

Refers applicants to support services as appropriate;

Determines continued eligibility for medical assistance;

Prepares and reviews required reports and maintains a client/provider tracking system;

Enters and codes data into automated information systems;

May oversee the work of clerical support staff;

Performs other related duties.  

Knowledge of Medical Care Program policies, procedures and regulations relevant to health care delivery systems;

Knowledge of basic math to prepare reports;

Ability to train and review the work of lower-level Medical Care Program Associates;

Ability to screen and respond to visitors and telephone inquiries;

Ability to maintain routine and confidential files, logs and program data;

Ability to review Medical Assistance data to interpret, clarify or apply Medical Care Program regulations, policies, procedures or guidelines;

Ability to collect and organize statistical information and prepare concise reports;

Ability to understand, access and operate various computer information systems;

Ability to organize findings and testify in administrative hearings;

Ability to operate office equipment and develop routine office procedures;

Ability to oversee the work of support staff;

Ability to communicate effectively with co-workers, supervisors and the general public.

Education:   Graduation from an accredited high school or possession of a high school equivalency certificate.

Experience: Three years of clerical experience applying policies in a medical care, health insurance or federal or State entitlement program.

Notes:

1. Candidates may substitute additional general clerical experience on a year-for-year basis for the required education.

2. Candidates may substitute thirty credit hours from an accredited college or university for one year of 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 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 D, Health and Human Service Nonprofessionals classes.  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial and confidential employees 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.

Employees in this classification are eligible to receive overtime compensation.  An employee who works more than the normal workweek is entitled to be compensated for that overtime, as provided by the State Personnel and Pensions Article, Section 8-305.