163910
MEDICAL CERTIFICATION SPECIALIST 1
MS518 $61,422 - $110,531
Creation Date: 08/05/1999
Change Date: 01/01/2025
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.
LEVEL OF WORK:SUPERVISION RECEIVED:Broad review from Medical Certification Supervisor or other higher level agency administrator.
SUPERVISION EXERCISED:JOB DISTINCTIONS:Differs from Medical Certification Specialist 2 by the absence of Centers for Medicare and Medicaid Services certification and by the level of independence exercised in carrying out work responsibilities.
CORE COMPETENCIES: CORE COMPETENCIES HAVE NOT BEEN IDENTIFIED BY STATE CIVIL SERVICE FOR THIS JOB TITLE.
MORE INFORMATION ON THE SCS COMPETENCY MODEL CAN BE FOUND
HERE.
EXAMPLES OF WORK:EXAMPLES BELOW ARE A BRIEF SAMPLE OF COMMON DUTIES ASSOCIATED WITH THIS JOB TITLE. NOT ALL POSSIBLE 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 Medicaid enrolled provider 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 the 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.
Conducts special investigations in response to complaints and prepares report findings.
Certifies individuals as medically eligible to receive waiver services.
Creates and monitors a continuous quality improvement process.
Approves waiver recipients' comprehensive plan of care and annually evaluates the overall effectiveness of waiver recipients' 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.
Evaluates the appropriateness and the quality of medical care based on personal observations, interviews, and/or established state performance standards.
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.
QUALIFICATION REQUIREMENTS:MINIMUM QUALIFICATIONS:
A current Louisiana license in a health services field, health regulation field, or social services field plus two years of experience in hospital or nursing home administration, health services, health regulation, or social services; OR
A bachelor's degree plus two years of experience in hospital or nursing home administration, health services, health regulation, or social services; OR
A master's degree in a health services field, health regulation field, or a social services field plus one year of experience in hospital or nursing home administration, health services, health regulation, or social services.