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#21-000928-0001
Supplemental Questionnaire

Last Name
First Name

 

**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1

Describe your administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below. 

2

Describe your experience participating in compliance reviews of health care providers.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

3

Describe your experience conducting on-site monitoring reviews and composing reports based on deficiency findings.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

4

Describe your experience with preparing procedural manuals, statistical reports and/or work-flow charts and performance measurement criteria.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

5

Describe your experience assisting in the implementation of monitoring specific programs, sub-programs or operational units.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

6

Describe your experience participating in the formulation, establishment or modification of program goals and objectives through analysis, trends and tracking available resources and projected program needs.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.


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