Health Care Compliance #49170

Health Care Compliance, #49170
Occupational Family: Health and Human Services
Pay Band Range: 4 - 6

Concept of Work

This Career Group provides career tracks for compliance specialists who are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, risk and safety, or operational practices. Responsibilities range from entry level professional to management. Employees inspecting medical facilities must be licensed as health care professionals.

Roles Comprising This Group

These roles describe the collective characteristics of the work performed by employees in the Health Care Compliance Career Group. The roles define the typical career paths for employees who pursue careers such as utilization review analysts, hospital quality assurance specialists, health care compliance specialists, and medical facility inspectors.

Although all of these occupations are compliance specialists, each warrants a separate career track. Each of these career paths requires different knowledge, skills, and abilities and would not naturally lead to the other for career progression. However, a role for each of these occupations represents different levels of work, or career progression. Career paths may exist within a single role, extend to other roles in this Career Group, or to roles in other occupationally related Career Groups.

PAY BAND	PRACTITIONER ROLES	ROLE CODE	MANAGEMENT ROLES	ROLE CODE
4	Health Care Compliance Specialist I	49171
5	Health Care Compliance Specialist II	49172
6			Health Care Compliance Manager	49173

Role Descriptions

These roles are distinguished based upon the Compensable Factors of Complexity, Results, and Accountability and are used for position classification. These factors should be used for classification and compensation analysis. Recruitment and selection standards must be based on knowledge, skills, and abilities as indicated in the Employee Work Profile.

Health Care Compliance Specialist I

Code: 49171

Pay Band: 4

SOC: 13-1041*

The Health Care Compliance Specialist I role provides career tracks for compliance specialists performing responsibilities ranging from entry level professional to first line supervisor. Employees audit, investigate, and inspect records, public and private operations, or facilities, to identify discrepancies in eligibility determinations, payment and billing calculations for individuals, third-party providers, or case records.

Health Care Compliance Specialist I

COMPLEXITY

Applies program rules and regulations in the resolution of human services programs.

Applies in-depth knowledge of one or more programs.

Frequent contact with service providers, recipients and their families, and representatives of other state and federal agencies on benefits and claims issues.

Employees conduct audits, inspections, or investigations of quality and utilization of services and may assist in promulgation review and revision of state licensure regulations operational guidelines.

May provide guidance to staff, clients, or others in private and public organizations.

May require knowledge of supervisory principles and practices.

RESULTS	Case, billing, pricing and redemption, and payment records are audited in accordance with applicable regulations and guidelines. Discrepancies are identified and a report-of-findings or other communication is initiated. Findings result in recommendations for, or provision of, corrective actions.
ACCOUNTABILITY	Directly accountable for the determination or detection of fraud, proper operation, and third party liability. May lead or supervise staff. Recommends licensure and certification of facilities. Accountable for program policy interpretation.

Health Care Compliance Specialist II

Code: 49172

Pay Band: 5

SOC: 13-1041* and 29-9099*

The Health Care Compliance Specialist II role provides career tracks for compliance specialists that either: plan and administer all aspects of a quality assurance, health care compliance, and utilization review programs; or are licensed health care professionals conducting inspections of service delivery and service providers.

Health Care Compliance Specialist II

COMPLEXITY

Applies rules, regulations, and laws in administration of programs.

Renders decisions on unusual problems involving policy interpretation.

Frequent contact with health care providers, program administrators, and representatives from state and federal agencies, and other direct and indirect human service providers to confer on policy problems and request legal opinions.

May require knowledge of supervisory principles and practices.

Implements and oversees corrective actions.

May testify at administrative appeals and hearings.

Inspectors may be required to have licensure.

RESULTS	Approves and/or recommends corrective actions/plans that affect programmatic operations (e.g., changes to policies, or procedures) Decisions may affect accreditation, licensure, and funding.
ACCOUNTABILITY	May lead or supervise staff. Evaluates program effectiveness and compliance. Develops administrative procedures. Some positions approve and issue licenses and certifications.

Health Care Compliance Manager

Code: 49173

Pay Band: 6

SOC: 11-9111* and 11-9199*

The Health Care Compliance Manager role provides career tracks for managers who manage and direct quality assurance, health care compliance, and utilization review program operations. The work includes development, implementation, and evaluation of operational goals, objectives, policies, procedures, legislative recommendations, and operating budget.

Health Care Compliance Manager

COMPLEXITY

Directs a major organizational component of an agency, requiring management of staff, programs, and administrative functions.

Applies knowledge of general managerial and financial management principles and practices for purposes of conducting and assessing short and long-range planning.

Collaborates with state and federal officials on program compliance.

May require knowledge of forecasting and statistical methods and procedures.

May provide expert testimony for administrative, criminal and civil cases.

May require licensure in a health services occupation.

RESULTS	Decisions made affect program outcomes, service quality, accreditation, licensure, and funding. Develops and implements business strategies and follows through with implementation. Decisions affect public perception of the regulatory programs’ effectiveness and expenditure of taxpayer dollars.
ACCOUNTABILITY	Leadership and supervision of staff. Responsible for evaluating program effectiveness and ensuring compliance with State and Federal statutes. Provides the highest level of consultation in the function. Relies on expertise and judgment to determine, plan and accomplish goals. May approve and issue licenses and certifications.

*Statistical Reporting

This Career Group includes, but is not limited to, those in the following Standard Occupational Classifications:

11-9111	Medical & Health Services Managers
11-9199	Managers, All Others
13-1041	Compliance Officers, Except Agriculture, Construction

New Effective Date: 11/01/01

History

Previous class titles (listed by new role title).

Health Care Compliance Specialist I

CLASS CODE	CLASS TITLE	GRADE
22501	Medical Assistance Program Representative	09
22503	Medical Assistance Operations Supervisor	09
46082	Social Services Quality Assurance Program Specialist	09
22181	WIC Program Representative	09
22062	Hospital Quality Assurance Coordinator	10
22081	Health Care Compliance Program Analyst	10
22502	Medical Assistance Program Representative Supervisor	10
41031	Utilization Review Analyst	10
22182	WIC Program Representative Senior	10
22064	Hospital Quality Assurance Assistant Director	11
22082	Health Care Compliance Program Analyst Senior	11
41032	Utilization Review Analyst Senior	11
46083	Social Services Quality Assurance Program Supervisor	11

Health Care Compliance Specialist II

CLASS CODE	CLASS TITLE	GRADE
22063	Hospital Quality Assurance Director	12
22083	Health Care Compliance Program Supervisor	12
22054	Medical Assistance Services Supervisor	12
41193	Medical Facilities Inspector	12
41162	Licensure/Certification Supervisor Senior	13
41196	Medical Facilities Inspection Supervisor	13

Health Care Compliance Manager

CLASS CODE	CLASS TITLE	GRADE
22084	Health Care Compliance Program Manager	15
41171	Licensure/Certification Program Manager	15
22507	Medicaid Operations Director	17