Occ. Code 5285100

 

 

ELIGIBILITY PROGRAM MANAGER 1, GRADE 27

5285100

ELIGIBILITY PROGRAM MANAGER 2, GRADE 29

5285200

ELIGIBILITY PROGRAM MANAGER 3, M-4

5285300

 

 

New York State Department of Civil Service

 

Classification Standard

 

BRIEF DESCRIPTION OF CLASS SERIES

 

          Positions in this title series administer and oversee bureaus and larger units within the Office of Health Insurance Programs and the New York State of Health that manage the New York State Medicaid Program, Child Health Plus Program, Qualified Health Plan coverage, and other public health insurance programs.  Incumbents direct, administer, and oversee all aspects of eligibility and enrollment for public health insurance programs.  Levels in the title series are distinguished by the scope of the program area or multiple programs managed, and the quantity and allocation of staff supervised.  

 

          These positions are classified at the Department of Health (DOH), Office of Health Insurance Programs (OHIP). 

 

Distinguishing Characteristics

ELIGIBILITY PROGRAM MANAGER 1: first managerial level; oversees the daily management of a limited or small public health insurance program, or serves as an assistant bureau director in a larger program, or over multiple programs.

 

ELIGIBILITY PROGRAM MANAGER 2: second managerial level; oversees a small bureau or a significantly large public health insurance program in a bureau, or multiple programs/units, or serves as an assistant bureau director in the largest bureaus.

 

ELIGIBILITY PROGRAM MANAGER 3: director level; directs a large bureau or medium-sized bureau that primarily consists of professional staff performing high-level administrative functions.

 

Related Classes

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.

 

Community Health Program Managers provide administrative and programmatic direction to a major public health/preventive health program or to multiple regional public health programs. Incumbents direct staff in a variety of activities, including public health outreach, coordination of public health programs and services with other State agencies and local health units, and the provision of technical assistance and oversight to public health service providers.

 

Illustrative Duties

          ELIGIBILITY PROGRAM MANAGER 1

Coordinates, manages, and oversees a unit or multiple units of subordinate staff engaged in the overall determination of eligibility and enrollment in a limited or small public health insurance program.

 

·       Provides supervision, guidance, and oversight to subordinate staff; intervenes and resolves problems as necessary. 

 

·       Determines and oversees staff assignments and reassignments; evaluates performance; monitors time and attendance; and approves leaves and the use of overtime. 

 

·       Directs staff in responding to intra and inter-agency correspondence, letters, telephone calls, and emails from the public, clients, stakeholders, oversight agencies, federal staff, members of the legislature, and health care provider community. 

 

·       Identifies training needs and arranges for the provision of training. 

 

·       Manages and directs program activities by setting priorities and deadlines. 

 

Assists in the development and implementation of program policies, procedures, and guidelines for the determination of eligibility in a public health insurance program.

 

·       Develops, refines, establishes, and implements program procedures and the activities necessary to determine eligibility and target eligible participants for public health insurance programs.

 

·       Evaluates public health insurance program data, including service levels, potential eligibles, target populations, public health trends, and program accountability.

 

·       Prepares and reviews reports of program activities. 

 

Implements and ensures adherence to federal eligibility regulations and State requirements. 

 

·       Provides clarification of federal eligibility regulations and State requirements to other Department of Health units, Fiscal Management, other State agencies, local program agencies, and other requesting entities. 

 

·       Represents the Department of Health and its public health insurance programs on various workgroups, cross-functional teams, and intra and inter-agency task forces concerned with public health insurance program eligibility and enrollment issues. 

 

Interprets federal and State laws, rules, and regulations to develop instructions, eligibility policy statements, directives, analyses, and other materials. 

 

·       Interprets guidelines and instructions related to eligibility issues; performs analysis for bureau and division-level staff; and makes recommendations for improvement.

 

·       Writes analytical reports and papers as required.

 

·       Collaborates with technical business systems and requirements analyst staff to develop automated systems programs and solutions. 

 

·       Reviews and updates prepared material used to train local program staff and entities engaged in the determination of eligibility and enrollment. 

 

·       Provides information for and direction to health care provider staff and recipients of public health insurance programs. 

 

·       May serve as contact or liaison with federal Centers for Medicare and Medicaid Services (CMS) staff and auditors. 

 

Oversees program review and management evaluation processes.

 

·       Develops and approves annual review schedules, final review reports, and corrective action submissions.

 

·       Analyzes and evaluates findings for trends and repetition, and recommends training topics from review findings. 

 

·       Analyzes and communicates to staff the impact of a variety of federal and State laws, rules, and regulations related to eligibility for public health insurance programs. 

 

Oversees program implementation and participation.

 

·       Develops policies and procedures, and communicates them to staff, local program agencies, and other entities engaged in the determination of eligibility for public health insurance programs. 

 

·       Develops and monitors plans for training and evaluation of program components and systems for documentation and reporting to meet federal and State requirements. 

 

·       Measures program growth and reduction by geographic region to ensure optimum participation levels. 

 

·       Implements efficiency measures based on cost-benefit analysis.

 

·       Directs outreach activities to ensure target populations are served. 

 

·       Directs evaluations activities designed to recognize program deficiencies in service levels or categories.  

 

May serve as an assistant bureau director in a larger program, or over multiple programs.

 

          ELIGIBILITY PROGRAM MANAGER 2

 

May perform all of the same duties and activities as an Eligibility Program Manager 1.

 

Directs, manages, and oversees a small bureau or a significantly large public health insurance program in a bureau, or multiple programs/units of subordinate staff engaged in the overall determination of eligibility and enrollment. 

 

·       Approves bureau policies, procedures, and guidelines for the statewide administration of public health insurance programs.

 

·       Develops Annual Plans for public health insurance programs. 

 

·       Oversees staff analysis of proposed and actual changes mandated by State and federal legislation and rule making, cost-saving initiatives, and improvements and updates of electronic systems.

 

·       Oversees expenditure plans for and monitors the use of federal and State program funds and resources. 

 

·       Oversees the development, implementation, and on-going maintenance of automated data systems.

 

·       Oversees the development of accountability, quality assurance, and quality control systems to ensure the appropriate use of funds and that target populations are reached. 

 

·       Maintains final approval of all agreements and amendments to agreements for participation in bureau programs, and ensures adherence to federal eligibility regulations and State requirements. 

 

Identifies program needs.

 

·       Determines bureau priorities and recommends approval for the procurements necessary to develop and maintain program services.

 

·       Determines bureau priorities for targeting low income participants and initiatives directed to improve participation in public health insurance programs. 

 

Serves as eligibility and enrollment expert to executive level staff, in audit situations with State and federal auditors, and as an expert witness in criminal and civil actions. 

 

·       Comments on proposed legislation and regulations, and emphasizes their impact on New York State, its public health insurance programs, and health care industry. 

 

·       Represents the State with national and regional professional organizations, task forces, workgroups, and other organized activities related to the determination of eligibility and enrollment in public health insurance programs. 

 

·       Develops and maintains on-going working relationships with federal funding agencies at the regional and national level, other State agencies providing related services, local governments, and other State and federal programs as necessary. 

 

May serve as an assistant bureau director in the largest bureaus. 

 

          ELIGIBILITY PROGRAM MANAGER 3

 

May perform all of the same duties and functions as an Eligibility Program Manager 1 and an Eligibility Program Manager 2. 

 

Directs, manages, and oversees the largest bureaus or a medium-sized bureau that primarily consists of professional staff performing high-level administrative functions related to the overall determination of eligibility and enrollment in public health insurance programs.

 


 

MINIMUM QUALIFICATIONS

 

          ELIGIBILITY PROGRAM MANAGER 1

 

Open-Competitive: a bachelors degree and four years of professional experience, two years of which must have included second-level supervision of staff, performing one or more of the following seven activities* in a program with one or more of the following functions: provides reimbursements 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.     Overseeing and directing staff in determining eligibility for a health insurance program or consumer assisted program in which financial eligibility criteria must be met.

 

2.     Overseeing and directing staff in 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.     Overseeing and directing staff in developing mechanisms for the reimbursement and financing of health care services, including rate-setting or approval, capitation reimbursement methodologies, fee schedule development, coding constructs for medical goods and services, or application and processing of reimbursement methodologies.

 

4.     Administering and overseeing staff responsible for day to day program operations for budgeting, staffing, or program planning.

 

5.     Overseeing and directing staff in inspecting, assessing, or monitoring health insurance programs or health care facilities for certification, licensure, or adherence to laws, rules, regulations, and policies.

 

6.     Overseeing and directing staff in planning, designing, developing, researching, or evaluating proposals to establish or refine health related programs, with responsibility for interpreting legislation or regulations, defining and describing target populations and local demographics, grant and proposal writing, or developing, reviewing, and evaluating contracts.

 

7.     Administering and overseeing staff responsible for performing quality assurance activities such as ensuring compliance with laws, rules, regulations, and policies, as it pertains to activities 1 through 6.

 

          ELIGIBILITY PROGRAM MANAGER 2

 

Open-Competitive: a bachelors degree and five years of professional experience, three years of which must have included second-level supervision of professional staff, performing one or more of the following seven activities* in a program with one or more of the following functions noted above in the Eligibility Program Manager 1 minimum qualifications.

 

          ELIGIBILITY PROGRAM MANAGER 3

 

Open-Competitive: a bachelors degree and six years of professional experience, four years of which must have included second-level supervision of professional staff, performing one or more of the following seven activities* in a program with one or more of the following functions noted above in the Eligibility Program Manager 1 minimum qualifications.

 

 

 

Date:  10/15

 

 

 

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 which 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.