Occ. Code 2580100

 

 

Medicaid Eligibility Examiner 1, Grade 9

2580100

Medicaid Eligibility Examiner 2, Grade 14

2580200

Medicaid Eligibility Examiner 3, Grade 17

2580300

Medicaid Eligibility Examiner 4, Grade 21

2580400

 

 

New York State Department of Civil Service

 

Classification Standard

 

Brief Description of Class SERIES

 

Medicaid Eligibility Examiners assist in or determine eligibility for Medicaid or public health insurance programs and provide technical assistance and guidance based on their expertise and knowledge of applicable legislation and programs to local social services districts, other Department of Health (DOH) program areas, other State agencies, consumers, health care providers, professional organizations, insurance companies, and advocacy groups.

 

These positions are classified only at the Department of Health, Office of Health Insurance Programs.

 

Distinguishing Characteristics

 

MEDICAID ELIGIBILITY EXAMINER 1:  entry level; as primary contact with the general public, receives and reviews applications for, and renewals of, public health insurance; provides information on public health insurance eligibility; determines eligibility; and collects appropriate documentation to support and maintain eligibility status of applicants.

 

MEDICAID ELIGIBILITY EXAMINER 2:  first supervisory level; supervises three or more Medicaid Eligibility Examiners 1 or other subordinate staff; provides information to various parties, including public health insurance applicants, local social service districts, and advocacy groups; analyzes and applies laws, rules, and regulations to make eligibility determinations; processes more difficult eligibility applications, making determinations or recommendations to supervisor on applications that do not fall within specified protocols and guidelines.

 

MEDICAID ELIGIBILITY EXAMINER 3:  second supervisory level; plans, coordinates, and supervises the activities of a small public health insurance eligibility enrollment function or a component of a large program, including supervision of two or more Medicaid Eligibility Examiners 2; reviews difficult or problematic applications or renewals and either makes a determination or a recommendation to supervisor.

 

MEDICAID ELIGIBILITY EXAMINER 4:  unit manager; administers and directs multiple public health insurance eligibility enrollment functions or a large program of 18 or more, including direct supervision of two or more Medicaid Eligibility Examiners 3; ensures adherence to laws, rules, and regulations, efficient program implementation, and consistent and correct application of eligibility guidelines; makes recommendations on administering public health insurance programs; reviews difficult or problematic applications or renewals; communicates program changes to subordinates and ensures changes are incorporated accurately. 

 

Related Classes

 

Medicaid Claims Examiners perform duties related to both the review of claims for payment of health care services provided under Medicaid and the enrollment and participation of both fee-for-service practitioners and institutional health care providers in the Medicaid program. 

 

Medical Assistance Specialists are professional level positions, often with a clinical or healthcare background, who perform a broad range of activities related to the development, administration, oversight, and implementation of the New York State Medicaid Program and other public health insurance programs within DOH. 

 

Illustrative Duties

 

          MEDICAID ELIGIBILITY EXAMINER 1

 

·       Receives applications for public health insurance electronically, by mail, telephone, or in person.

 

·       Obtains additional information omitted by applicant either directly from the applicant or from the appropriate agency, local government, or other accessible source on behalf of the applicant.

 

·       Processes eligibility applications by reviewing information and identifying inconsistencies or questions that may warrant additional review or investigation.

 

·       Researches applicants status, prior history, and payment history, utilizing various data systems to determine eligibility.

 

·       As necessary, contacts cooperating agencies (e.g. Social Security Administration, Centers for Medicare and Medicaid) to verify applicants documentation for eligibility or to clarify information being supplied.

 

·       Identifies applicants eligibility for program(s), e.g. Medicaid, Child Health Plus, Family Health Plus, or other qualified program.

 

·       Issues appropriate notices and information to applicants when their application is either approved or denied, using approved form letters and explanatory documents.

 

·       Consults with supervisor on unusual or problematic applications and situations or if an applicant becomes difficult, irate, or abusive.

 

          MEDICAID ELIGIBILITY EXAMINER 2

 

·       Assists in planning and conducting staff training in response to identified needs or when new or revised regulations and procedures are introduced.

 

·       May provide or develop written material and orally explain and answer questions.

 

·       Schedules work, monitors workload volumes, and reassigns staff to ensure timely determination of new or continued eligibility as well as equitable work distribution.

 

·       Monitors the quantity and quality of work completed by staff to ensure accuracy and adherence to procedures and instructions; identifies and resolves inaccuracies.

 

·       Performs the full range of supervisory duties including approving time off, maintaining time and attendance, conducting performance evaluations, and counseling subordinates in the performance of their work and in their adherence to employee policies.

 

·       Responds to inquiries for information from various sources about applicable laws, rules, and regulations in connection with Medicaid eligibility. 

 

·       Addresses specific concerns for resolution of unusual or problematic applications, or consults with supervisor in exceptional situations or if an applicant becomes difficult, irate, or abusive.

 

·       Based on analyses of information provided by applicants and subordinates, makes eligibility determinations on applications that fall within specified protocols and guidelines.

 

·       Drafts written correspondence in response to questions from consumers, legislative staff, and other interested parties.

 

·       Drafts papers to explain problems or deficiencies, and proposes solutions to resolve problematic applications to supervisor or manager of the insurance program.

 

·       Prepares, compiles, and organizes data for various operating and management reports.

 

·       Develops and reviews eligibility scenarios to test new computer applications and systems.

 

·       May serve as a paraprofessional to provide support to professional positions in staff bureaus and to provide expertise regarding Medicaid policy and operations pertaining to benefits and services, eligibility, and public/private health insurance policy. 

 

          MEDICAID ELIGIBILITY EXAMINER 3

 

·       Serves as a second level supervisor to Medicaid Eligibility Examiners 2 and other subordinate positions. 

 

·       Interacts with consumers and advocates regarding various public health insurance programs and serves as a mediator with irate or difficult applicants. 

 

·       Based on analyses of information provided by applicants and subordinates, makes eligibility determinations on applications that do not fall within specified protocols and guidelines.

 

·       May conduct extensive research using resources both within and outside of the unit to prepare reports and recommendations for resolution of significant issues to supervisor.

 

·       Provides technical assistance and direction within assigned area of responsibility to subordinate staff and others.

 

·       Assigns and reviews work of subordinate staff by monitoring the quantity and quality of work completed to ensure accuracy and adherence to procedures and instructions; identifies and resolves inaccuracies.

 

·       Reviews, analyzes, and organizes data for various operating and management reports.

 

·       Assists program areas with quality improvement activities on a continual basis.

 

·       Develops and reviews eligibility scenarios to test new computer applications and systems.

 

·       May appear at judicial or administrative proceedings to address questions and determinations on eligibility for coverage.

 

          MEDICAID ELIGIBILITY EXAMINER 4

 

·       Administers and directs multiple public health insurance eligibility enrollment functions or a large program of 18 or more subordinates.

 

·       Plans and conducts, or arranges for training of staff and/or relevant stakeholders in response to identified needs or when new or revised regulations and procedures are introduced.

 

·       May develop written materials to aid in training or to provide guidelines to subordinates or others. 

 

·       Plans, conducts, and/or oversees training of Medicaid Eligibility Examiner Trainees.

 

·       Serves as a mediator on issues with the most difficult applicants.

 

·       Reviews, signs, or authorizes the most difficult and problematic eligibility determinations.

 

·       Establishes necessary criteria for determining unit performance and oversees personnel activities including training, performance evaluations, and disciplinary actions.  

 

·       Monitors the quantity and quality of work completed by staff to ensure accuracy, efficiency, and adherence to procedures and instructions; identifies and resolves inaccuracies, and takes action to avoid repetition of errors. 

 

·       Establishes and maintains effective working relationships with other units, divisions, and departments of the agency as well as other county agencies and community groups to facilitate the processes and delivery of public health insurance and the dissemination of information and education regarding public health insurance.

 

·       Interprets and communicates a variety of Federal and State laws and codes to implement policies and procedures and maintain compliance in the delivery of public health insurance benefits. 

 

·       Analyzes policies and procedures and utilizes cost/benefit analyses to identify, develop, and implement efficiency measures.

 

·       Makes recommendations consistent with eligibility laws, rules, and regulations to managerial staff on administering New Yorks public health insurance programs.

 

·       Prepares or reviews correspondence in response to questions from consumers, legislative staff, and other interested parties.

 

·       Formulates and maintains statistical reports for functions within areas of responsibility.

 

·       Maintains records and reports in accordance with federal and state requirements.

 

·       Serves as a subject matter expert at judicial or administrative proceedings in addressing questions regarding eligibility determinations.

 

Minimum Qualifications

 

          MEDICAID ELIGIBILITY EXAMINER 1

 

Promotion:  satisfactory completion of one year as a Medicaid Eligibility Examiner Trainee

 

Open Competitive: two years of full-time experience performing one or more of the following activities,* in a program with one or more of the following functions:

 

·       Reimburses for health care services;

·       Works with social services program areas;

·       Determines eligibility for a consumer assisted program in a hospital or other health care facility;

·       Provides health care regulatory oversight; or

·       Performs quality assurance and interpretation/application of standards of health care.

 

*Activities:

 

  1. Reviewing and/or determining eligibility for a health care program in which financial eligibility criteria must be met;

2.     Performing utilization review, including pre-payment or post-payment review of requested health care services, prior approval or authorization activities, adjudication or pricing of claims for payment; or analysis of patterns of health care;

  1. Determining reimbursement and financing of health care services, including rate-setting or approval, establishing capitation reimbursement methodologies, assessing fee schedules, coding constructs for medical goods and services, or applying/processing of reimbursement methodologies;
  2. Performing quality assurance activities such as ensuring compliance with laws, rules, regulations, and policies;

Substitution:  College credit hours may substitute for up to one year of experience at the rate of 30 college credits equaling one year of experience.

 

          MEDICAID ELIGIBILITY EXAMINER 2

 

Promotion:  satisfactory completion of one year permanent competitive service as a Medicaid Eligibility Examiner 1.

 

Open Competitive: four years of full-time experience performing one or more of the following six activities,* in a program with one or more of the following functions:

 

·       Reimburses for health care services;

·       Works with social services program areas;

·       Determines eligibility for a consumer assisted program in a hospital or other health care facility;

·       Provides health care regulatory oversight; or

·       Performs quality assurance and interpretation/application of standards of health care.

 

*Activities:

 

  1. Determining eligibility for a health care program in which financial eligibility criteria must be met;

2.     Performing utilization review, including pre-payment or post-payment review of requested health care services, prior approval or authorization activities, adjudication or pricing of claims for payment; or analysis of patterns of health care;

  1. Determining reimbursement and financing of health care services, including rate-setting or approval, establishing capitation reimbursement methodologies, assessing fee schedules, coding constructs for medical goods and services, or applying/processing of reimbursement methodologies;
  2. Performing quality assurance activities such as ensuring compliance with laws, rules, regulations, and policies;
  3. Inspecting, assessing, or monitoring health care programs or facilities for certification, licensure, or adherence to laws, rules, regulations, and policies;
  4. Planning, designing, developing, researching, or evaluating proposals to establish or refine programs, with ongoing responsibility for interpreting legislation or regulations, defining and describing target populations and local demographics, grant and proposal writing, or developing, reviewing, and evaluating contracts.

Substitution:  college credit hours may substitute for up to two years of experience at the rate of 30 college credits equaling one year of experience.

 

          MEDICAID ELIGIBILITY EXAMINER 3

 

Promotion: satisfactory completion of one year permanent competitive service as a Medicaid Eligibility Examiner 2.

 

Open Competitive: five years of full-time experience, one year of which must have included supervision of staff, performing one or more of the following six activities,* in a program with one or more of the following functions:

 

·       Reimburses for health care services;

·       Works with social services program areas;

·       Determines eligibility for a consumer assisted program in a hospital or other health care facility;

·       Provides health care regulatory oversight; or

·       Performs quality assurance and interpretation/application of standards of health care.

 

*Activities:

 

1.     Determining eligibility for a health care program in which financial eligibility criteria must be met.

 

2.     Performing utilization review, including pre-payment or post-payment review of requested health care services, prior approval or authorization activities, adjudication or pricing of claims for payment; or analysis of patterns of health care.

 

3.     Determining reimbursement and financing of health care services, including rate-setting or approval, establishing capitation reimbursement methodologies, assessing fee schedules, coding constructs for medical goods and services, or application/processing of reimbursement methodologies.

 

4.     Performing quality assurance activities such as ensuring compliance with laws, rules, regulations, and policies.

 

5.     Inspecting, assessing, or monitoring health care programs or facilities for certification, licensure, or adherence to laws, rules, regulations, and policies.

 

6.     Planning, designing, developing, researching, or evaluating proposals to establish or refine programs, with ongoing responsibility for interpreting legislation or regulations, defining and describing target populations and local demographics, grant and proposal writing, or developing, reviewing, and evaluating contracts.

 

Substitution:  college credit hours may substitute for up to two years of non-supervisory experience at the rate of 30 college credits equaling one year of experience.

 

          MEDICAID ELIGIBILITY EXAMINER 4

 

Promotion: satisfactory completion of one year of permanent competitive service as a Medicaid Eligibility Examiner 3.

 

Open Competitive: six years of full-time experience, two years of which must have included supervision of staff, performing one or more of the following six activities,* in a program with one or more of the following functions:

 

·       Reimburses for health care services.

·       Works with social services program areas.

·       Determines eligibility for a consumer assisted program in a hospital or other health care facility.

·       Provides health care regulatory oversight.

·       Performs quality assurance and interpretation/application of standards of health care.

 

*Activities:

 

1.     Determining eligibility for a health care program in which financial eligibility criteria must be met.

 

2.     Performing utilization review, including pre-payment or post-payment review of requested health care services, prior approval or authorization activities, adjudication or pricing of claims for payment; or analysis of patterns of health care.

 

3.     Determining reimbursement and financing of health care services, including rate-setting or approval, establishing capitation reimbursement methodologies, assessing fee schedules, coding constructs for medical goods and services, or applying/processing of reimbursement methodologies.

 

4.     Performing quality assurance activities such as ensuring compliance with laws, rules, regulations, and policies.

 

5.     Inspecting, assessing, or monitoring health care programs or facilities for certification, licensure, or adherence to laws, rules, regulations, and policies.

 

6.     Planning, designing, developing, researching, or evaluating proposals to establish or refine programs, with ongoing responsibility for interpreting legislation or regulations, defining and describing target populations and local demographics, grant and proposal writing, or developing, reviewing, and evaluating contracts.

 

Substitution:  College credit hours may substitute for up to three years of non-supervisory experience at the rate of 30 college credits equaling one year of experience.

 

 

Date:  3/15

 

 

 

NOTE: Classification Standards illustrate the nature, extent, and scope of duties and responsibilities of the classes they describe.  Standards cannot and do not include all of the work that might be appropriately performed by a class.  The minimum qualifications above are those that were required for appointment at the time the Classification Standard was written.  Please contact the Division of Staffing Services for current information on minimum qualification requirements for appointment or examination.