Medical Care Program Associate I

POSITION DESCRIPTION

Medical Care Program Associate I

POSITION FUNCTIONS

1. MAIN PURPOSE OF THE JOB: Briefly describe the main purpose of this position and how it relates to the mission of the agency.

This position acts as a telephone triage agent, to various 800 hotlines for the HealthChoice and Acute Care Administration in the Division of HealthChoice Customer Relations by providing customer service and resolution of recipient and provider concerns for various Medicaid programs which include but are not limited to HealthChoice, Medicaid Expansion Programs, Maryland Children’s Health Program (MCHP), Family Planning program. All Inquiry and Complaint calls document the enrollee and provider problems and issues in the Provider Recipient Ombudsman Management Information System (PROMIS). This also includes education of recipients and providers regarding navigation and access of the Medicaid system by reviewing state and federal regulations, policies, and procedures. The agent is required to triage all medical complaints from recipients and providers in the Medicaid Programs and is required to document the complaint/issue in the PROMIS database. All complex complaints are referred to the Complaint Resolution Unit within the Division of Outreach and Care Coordination.

2. ESSENTIAL JOB FUNCTIONS AND OTHER ASSIGNED DUTIES - List duty and

responsibility statements that identify the essential job functions and other assigned duties.

Essential job functions are the fundamental job duties of a position that if not performed

will alter the job. (Identify essential job functions by highlighting, underlining, etc.)

3. LEVEL, FREQUENCY AND PURPOSE OF WORK CONTACTS: List the contacts that this

position has with individuals within the division, agency and department as well as other State

agencies, other government agencies, private companies, clients, customers, vendors and the

general public. These contacts may be in person, in writing or by telephone. Indicate how

often the contact occurs. State the purpose of each contact, for example, to provide

information, to explain procedures or decisions, to persuade or negotiate.

Daily contact with CRU in order to educate and refer complaints.

Daily contact with internal/external resources in order to educate and resolve inquiries and complaints.

Daily contact with staff in Medical Care Programs to obtain policy clarification and disseminate

information.

Daily contact with staff in Operations and Eligibility in order to receive and disseminate information.

Daily contact with liaisons in Managed Care Organizations in order to receive and disseminate information and to resolve complaints.

Daily contacts with Enrollment Broker in order to receive and disseminate information and to resolve complaints.

4. DECISIONS AND RECOMMENDATIONS: List the decisions and recommendations that this

position make which are necessary to carry out essential job functions. State to whom

recommendations are made.

Decides on strategies to resolve Inquiries/complaints and execute those strategies with those people or organizations necessary to implement a resolution.

Decides on strategies to resolve recipient billing complaints and execute those strategies with providers and MCOs and billing companies, as appropriate.

Decides on the appropriate resources necessary to the implementation of a complaint resolution and contact those resources.

Recommends to Supervisors, after review of complaint trends, what processes or procedures could be amended to provide more efficient assistance to providers.

5. EQUIPMENT USED - List equipment, machinery and tools used to complete this job, e.g.,

personal computer, calculator, typewriter, hand tools, measuring devices and lab equipment. Personal computer and automated phone system with headsets.

6. NATURE OF SUPERVISION RECEIVED - Check the type of supervision that is given to

this position. See Instructions part II, Item 6 for definition of terms.

Close Supervision

X Moderate Supervision

General Supervision

Managerial Supervision

RESPONSIBILITY FOR THE WORK OF OTHERS

NATURE AND LEVEL OF RESPONSIBILITY FOR WORK OF OTHERS:

This section should be completed if this position is responsible for the work of others, this includes

full and part-time permanent employees, contractual or emergency employees, volunteers, reimbursable or loaned employees. If additional space is required, attach a separate sheet.

A supervisor assigns and reviews the work of others, trains employees, recommends the selection, promotion and termination of employees, approves leave and signs timecards, signs annual performance evaluations, determines and resolves procedural problems within the unit, serves as spokesperson for subordinates, explains policies and directives from management and issues formal disciplinary reminders, warnings and reprimands.

PERFORMANCE STANDARDS

PERFORMANCE STANDARDS - For each essential job function described in Part II, list the standard(s) necessary for satisfactory performance. If additional space is required, attach a separate sheet.

Log into ACD system when arriving at duty station. Consistently remains in the Ready

mode to receive calls. Go into Work or Break modes only to document calls, go on break and at lunch time.

Educates enrollees/providers on Medicaid regulations and Medicaid service delivery system. Has a complete working knowledge of Medicaid federal and state regulations and policies and delivers that information in a clear and accurate manner.

Provides excellent Customer Service i.e. identifies self and organization and maintains a courteous and polite demeanor at all times or requests assistance from supervisor per SOPS.

Responds to Enrollee/Provider issues/complaints – Identifies the issue/complaint and confirms with its nature. Seeks a complete referral or resolution and reports back to all concerned parties.

Understands all appropriate procedures for making referrals to internal and external resources.

Collects and logs information into a special dedicated PC database – The data screen will be completed to the extent possible. All of the required data, coding, and narratives will be accurate and complete. Information will be place in the database in the proper format.

Documents call issues in a clear and concise manner including who, what, where, when and how. Reader should be able to understand the issue without further clarification. Codes and pop-up boxes should reflect accurately the essence of the call. Proofread for accuracy.

Refers providers to appropriate resources – An accurate assessment will be made of the requirements of the provider and the appropriate resource will be selected for the issue at hand. That resource will be able to resolve or respond to the providers needs.

Prepares weekly and monthly reports on Hotline activities. Uses Tally guidelines correctly to log misdirected and redirected calls.

Educates providers/public – All information disseminated will be accurate, complete and appropriate to the inquiry. Confidential information will not be released. Provide prompt assistance to members in need of technical assistance, timely completion of updates to PROMIS system when needed.