MINIMUM QUALIFICATIONS:
A baccalaureate degree plus three years of professional level experience in hospital or nursing home administration, public health administration, social services, nursing, pharmacy, dietetics/nutrition, physical therapy, occupational therapy, medical technology, or surveying and/or assessing health or social service programs or facilities for compliance with state and federal regulations.
SUBSTITUTIONS:
A current valid Louisiana license in one of the qualifying fields will substitute for the required baccalaureate degree.
A master's degree in hospital administration, nursing home administration, public health administration, social work, nursing, pharmacy, dietetics, nutrition, physical therapy, occupational therapy, or medical technology will substitute for a maximum of one year of the required experience.
NOTE:
Any college hours or degree must be from an accredited college or university.
NOTE:
A current valid Louisiana license in an individual field may be required for some positions.
NECESSARY SPECIAL REQUIREMENT:
FOR HEALTH STANDARDS SECTION JOBS ONLY
Federal regulations may mandate additional requirements prior to appointment.
FUNCTION OF WORK:
To conduct surveys and/or assessments to verify that the services provided to individuals by providers, facilities, waivers, and/or long term care programs are in compliance with federal certification, state regulations, and established state standards. The Medical Certification Specialist 2 (Med Cert) manages a caseload of recipients who are linked for a Home and Community Based Waiver (HCBW). Receives and reviews in detail all components of an individual's initial comprehensive plan of care for approval for home and community-based services deciding within 10 business days of receipt as identified in federal and state guidelines. Minimum components of the plan of care includes: Medicaid Form 148 (information regarding Admissions/Discharges/Status Changes), 90L (medical information), Behavior Support Plan, Staffing Plan/Emergency Preparedness Information, Wavier Rights and Responsibilities, Freedom of Choice for Support Coordination, and Service Agency, Home/Worksite Diagram, as well as, Comprehensive Plan of Care outlining all information regarding person's disability, social supports, medical/psychiatric/psychological information, hours of staff support requested, financial costs of services as requested, and non-waiver funded supports and services.
LEVEL OF WORK:
Advanced.
SUPERVISION RECEIVED:
Broad direction from Medical Certification Supervisor or other higher level agency administrator.
SUPERVISION EXERCISED:
None.
LOCATION OF WORK:
Department of Health and Hospitals.
JOB DISTINCTIONS:
Differs from Medical Certification Specialist 1 by the possession of the Centers for Medicare and Medicaid Services certification and by the level of independence exercised in carrying out work responsibilities.
Differs from Medical Certification Supervisor by the absence of supervisory responsibilities.
EXAMPLES LISTED BELOW ARE BRIEF SAMPLES OF COMMON DUTIES ASSOCIATED WITH THIS JOB TITLE. PLEASE NOTE THAT NOT ALL TASKS ARE INCLUDED.
Conducts surveys of health and social services programs, facilities, and providers that are state licensed and/or certified for state and federal programs.
Conducts assessments to ensure receipt of quality services by contracted providers.
Studies the facility or other enrolled providers relative to quality of medical services to determine the extent of compliance with state/federal regulations, state licensing, or established state standards.
Obtains information from review of records, staff interviews, resident interviews, personal observations relative to the operation of the medical facility, compliance standards, and quality of medical care provided.
Evaluates equipment and environmental factors of a facility for compliance with federal and state regulations.
Compiles information derived from surveys or paid Medicaid claims data and reports findings to recommend whether licensure and/or certification should be granted, denied, deferred, continued, or a change in Medicaid reimbursement is warranted.
Evaluates the appropriateness and the quality of medical care based on personal observations, resident interviews, or established state performance standards.
Presents survey findings to staff and/or governing bodies of facilities.
Conducts special investigations in response to complaints and reports findings.
Certify individuals as medically eligible to receive waiver services.
Creates and monitors a continuous quality improvement process.
Approves waiver recipient comprehensive plan of care and annually evaluates the overall effectiveness of waiver recipient comprehensive plan of care. Ensures that personal outcomes resulting from the receipt of waiver services are reflective of the person-centered goals identified in their comprehensive plan of care.
Conducts quality assurance of case management agencies and service providers relative to organization, policies and procedures, administration, qualifications of staff and quality of services to determine the extent of compliance with Medicaid regulations and waiver recipients comprehensive plan of care.
Receives, reviews, and determines appropriateness of recipient appeals of denied services. Gathers factual information and prepares summary of evidence. Presents testimony before Administrative Law Judge.
