State of Montana Program Officer (07040) in Helena, Montana
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Job Overview: The Health Resources Division seeks to provide health care for low-income and disabled Montanans through the Montana Healthcare Programs. As a Program Officer, this position is responsible for the Montana Healthcare Programs Rural Health Center (RHC), and Federally Qualified Health Centers (FQHC) Programs. Other responsibilities include: 1) Working with the administrative rules, statutes, and policies concerning RHC, and FQHC; 2) Working with members and providers concerning services, billing, and placement when coming back into the state after receiving out-of-state services; 3) Coordinating program changes in the Montana Medicaid Information System (MMIS) due to Medicaid changes and 4) assisting the Hospital Program Officer.
Major Duties or Responsibilities:
• Develops and implements program health benefit coverage and reimbursement procedures based on state and federal Medicaid requirements, Administrative Rules of Montana (ARM), State Plan and other regulations.
• Writes and updates administrative rules, statutes, and policies concerning inpatient and outpatient payment methodology of hospital billing, coding, and administration of benefits and payment services.
• Develops, implements, and monitors attainment of program goals and objectives.
• Conducts File Updates Requests (FUR), checks and approves system files for uploads and makes recommendations for system changes based on federal changes, errors, etc.
• Provides testimony on reimbursement rules and coverage when required at rule hearings, administrative reviews and fair hearings.
• Develops proposals for inclusion in the executive budget for approval and funding of new approaches to service delivery and reimbursement.
• Communicates with stakeholders, providers, contractors, agents, other payers, federal agencies, and clients and resolves policy issues and reimbursement disputes.
• Recommends comprehensive strategies to ensure the efficient operation of the program.
Technical Program Oversight
• Serves as liaison to address coverage, reimbursement or eligibility issues.
• Maintains provider relations and information network through oral and written communications, including group presentations and meetings to ensure patient access to services.
• Develops assessment tools such as reports, spreadsheets, queries, etc. and reviews paid claims data, denied claims, and utilization of services to ensure program quality and compliance.
• Represents the bureau and actively participate as a subject matter expert for department data and claims processing systems. Provides input and feedback for design of the new systems such as necessary features and display requirements and functionality tests.
• Participates in medical coverage reviews, setting of medical procedure limits, and determination of medical necessity.
• Compiles, develops, researches, and evaluates innovative alternatives and options to current benefit design, health care coverage, and policy. Documents justification considering impact on Medicaid, other state agencies, other payers, federal government, clients, providers and the public.
• Designs and implements payment systems to reimburse and account for services provided, and provide accurate historical information to evaluate perform of programs.
Hospital Section Services Duties
• Review applications, determine reimbursement rates (initial and final), and prepare and submit File Update Request (FUR). Works with the Accountant on cost settlements.
• Functions as the Subject Matter Expert on Physician Administered Drugs. Processes prior authorization requests with the Medicaid Pharmacist or contracted pharmacist. Issues decision letters to interested parties.
• Responds to provider inquiries on payment/coverage issues and denials. Interprets policy, rule and law and researches and resolves the more complex denial issues.
• Prepares letters for denial. Corrects over and under payments to providers.
Physical and Environmental Demands:
Work is performed in a typical office environment with keyboarding responsibilities. Minimal travel for provider education/conferences less than 5%
Knowledge, Skills and Abilities (Behaviors):
Required for the first day of work:
• General knowledge of Medicaid and medical terminology.
• Knowledge of program management principles and practices.
• Ability to analyze math calculations.
• Expertise in spreadsheet software (Excel)
• Excellent interpersonal and customer service skills.
• Excellent written and verbal communication skills.
• Ability to interpret and apply laws, rules and regulations.
• Ability to identify and solve problems.
• Knowledge and understanding of large databases including manipulation of data and the impact of changes.
Required Minimum Education and Experience:
• Bachelor’s degree in human services; business, public, or health administration; or other related fields.
• Two years of job related work experience in health policy, health program development, or health administration.
• Other combinations of directly related education and experience may be considered on a case-by-case basis.
• Experience in the medical service delivery system is preferred.
Job: *Project/Program Management
Title: Program Officer (07040)
Requisition ID: 18142014