What are the responsibilities and job description for the Utilization Review Specialist position at Dept of Health Care Finance?
JOB SUMMARY
This position is located in the Department of Health Care Finance (DHCF), Program Integrity Administration. The mission of the Department of Health Care Finance is to improve health outcomes by providing access to comprehensive, cost-effective, and quality healthcare services for residents of the District of Columbia. The position serves as a Utilization Review Specialist that organizes, implements, and evaluates health care utilization review and utilization control activities intended to ensure proper payment procedures and to prevent and detect abuse and possible fraud by persons who provide and receive services financed by DHCF.
DUTIES AND RESPONSIBILITIES
Conducts utilization review of Medicaid claims data. Conducts and reviews audits of independent providers to identify incorrect utilization and billing practices. Prepares, tracks and reviews recoveries of provider payments. Identifies areas at high risk of mis-utilization, underutilization and over utilization of DHCF financed programs. Identifies the need for and develops and implements methods to modify or create analysis criteria to identify and/or quantify provider and recipient abuse, mis-utilization, or overutilization of health care services. Develops recommendation or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid moneys or to suspend or terminate program participation. Performs utilization review activities, such as prior authorizations and medical necessity. Coordinates utilization management activities with DHCF program areas, such as long-term care programs.
Selects audit samples, prepares audit criteria, and coordinates audit activities with other team members to ensure audit timeliness. Develops and prepares audit analysis and deficiencies reports as well as complies supporting documentation. Assists with reviewing and analyzing program utilization data and/or medical documentation Le. patient charts and evaluate services provided or received to assess compliance with DHCF program policies, standards, and appropriateness of services and/or medical necessity. Conducts on-site inspections, interviews providers and recipients. Reviews requests to determine appropriateness of authorization of services and/or payments for various health care services delivered based on medical necessity appropriateness of services and coverage guidelines.
QUALIFICATION AND EDUCATION
Specialized Experience: Specialized experience is an experience which is directly related to the position and has equipped the individual with the knowledge, skills, and abilities to successfully perform the duties of the position. To be creditable, at least one (1) year of specialized experience must have been equivalent to at least the next lower grade level in the normal line of progression.
LICENSES AND CERTIFICATIONS
None
WORKING CONDITIONS/ENVIRONMENT
The work is performed in an office setting and sedentary in nature.
OTHER SIGNIFICANT FACTS
Tour of Duty: 8:15 am – 4:45 pm (Monday thru Friday)
Career Service – Term. Term Appointment – Not-To-Exceed (NTE) 13 months. A Term employee does not acquire permanent status on the basis of his/her term appointment. Continued employment under this appointment is contingent upon availability of funding.
Pay Plan, Series and Grade: CS-301-12
Promotion Potential: No known promotion potential
Collective Bargaining: This position is not covered under a collective bargaining unit.
Position Designation: This position has been deemed security sensitive. Accordingly, the incumbent will be subject to pre-employment checks (criminal background, consumer credit check, traffic record check and drug testing, if applicable) as a condition of employment, and will be subject to periodic criminal background checks for the duration of tenure.
EEO Statement: The District of Columbia Government is an Equal Opportunity Employer. All qualified candidates will receive consideration without regard to race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, physical handicap, or political affiliation.
