Occ. Code 5504000

 

 

MEDICAL CARE REPRESENTATIVE, GRADE 19

5504000

SUPERVISING MEDICAL CARE REPRESENTATIVE, GRADE 23

5504010

PRINCIPAL MEDICAL CARE REPRESENTATIVE, GRADE 25

5504020

CHIEF MEDICAL CARE REPRESENTATIVE, M-2

5504030

 

New York State Department of Civil Service

Classification Standard

BRIEF DESCRIPTION OF CLASS SERIES

Medical Care Representatives are registered professional nurses who assure the comprehensive medical rehabilitation of injured workers through coordination of medical assessments, evaluations, recommendations, referrals, and payments.  They are found in several State agencies with the majority of positions located in the business units of the New York State Insurance Fund (SIF). 

 

DISTINGUISHING CHARACTERISTICS

MEDICAL CARE REPRESEnTATiVE:  responsible for the management of a caseload (typically 25 to 35 cases), of high cost, long term, medically complex cases; mentor Claims Services Representatives in the review of medical aspects of claims administration.

SUPERVISING MEDICAL CARE REPRESENTATIVE: first supervisory level; trains and provides technical oversight and direction to Medical Care Representatives; may independently manage or review the most legally and medically complex cases.

            PRINCIPAL MEDICAL CARE REPRESENTATIVE: second supervisory level; functions as regional manager; provides technical supervision of all Medical Care Representative staff in assigned region through the review, coordination, and approval of decisions on high cost cases.

            CHIEF MEDICAL CARE REPRESENTATIVE: the agencys Statewide medical care program manager.

RELATED CLASSES

Community Mental Health Nurses are members of multi-disciplinary clinical treatment teams providing total therapy programs tailored to the individual needs of mentally ill or developmentally disabled clients in the community.  As the medical and psychiatric nursing care specialist on a treatment team, provides direction, assistance, consultation and instruction to team members on all aspects of medical and psychiatric nursing care.

 

Utilization Review Coordinators analyze individual patient records to determine the appropriateness of admissions and continued stay in health care facilities; review treatment plans against established criteria and standards to assure treatment is consistent with good medical practice; assure the necessity for admission to a health care facility; the necessity for continued stay at that level of care; and the appropriateness of the plan of care to the patients manifested condition.

Disability Analysts 2 review, evaluate and adjudicate initial, continuing, and other individual disability claims under the provisions of the Social Security Act and special programs to determine the claimant's eligibility for such benefits.  Disability Analysts 2 review the cases; develop and obtain medical, vocational, and other relevant information; evaluate all of the information obtained, including that provided by the claimant; and independently determine the claimant's case.

ILLUSTRATIVE DUTIES

MEDICAL CARE REPRESENTATIVE

Manages cases that are more medically complex and costly.

Reviews initial health care and vocational assessments.

 

 

 

Authorizes and executes the payment of compensation to claimants.

Assists the hospital in discharge planning and arranges for home care or equipment.

·        Makes recommendations for continuing medical care and therapeutic rehabilitation and analyzes alternative treatment options.

Identifies, coordinates, and refers cases for vocational rehabilitation in those offices where there is no in-house vocational rehabilitation counselor.

Authorizes supplies, equipment, home care services, and other medical necessities.

Reviews and approves any home or vehicle modifications.

·        Coordinates with architects and contractor services, as appropriate under the treatment plan.

Monitors the activities of rehabilitation vendors.

 

 

 

Coordinates medical case management and early return to work programs with Policyholder Services and Underwriting staff.

Assists Hearing Representatives in preparing cases for Workers Compensation Board hearings.

 

Initiates and negotiates settlements under Section 32 of the Workers Compensation Law.

Serves as a technical medical resource/mentor for the business unit team.

 

 

 

 

 

 

 

 

 

 

Approves and executes the payment of medical bills on assigned cases.

May prepare cases for and participate in high cost case committee meetings.

SUPERVISING MEDICAL CARE REPRESENTATIVE

Provides technical supervision to Medical Care Representatives.

 

 

Provides technical assistance/guidance for the more complex, controverted, sensitive or high cost claims.

Reviews and approves recommendations for extensive and/or unusual continuing care and treatments.

Approves the referral of patients to private rehabilitation providers in cases requiring extensive case management.

Ensures that information in the Claims Handling System (CHS) entered by Medical Care Representatives is current, accurate, and readily retrievable for review and use by supervisory staff.

Develops Life Care Planning Assessments and initiates Medicare Set Aside Trusts for structured settlements.

Serves as technical medical expert for high cost Section 32 settlements.

Presents and defends cases at Statewide High Cost Case Review Committee meetings.

Reviews and responds to medical provider billing complaints and defends SIFs position at Medical Arbitration and/or Workers Compensation Board hearings.

Assists Counsel in the preparation of cases for litigation.

Negotiates proposed Section 32 settlements for the most medically and legally complex cases.

Personally handles the most difficult cases.

May perform any of the duties assigned to a Medical Care Representative.

Reviews, coordinates and approves the Medical Care Representatives' management of high cost cases, including their entire caseload for quality and quantity.

Coordinates and oversees MCR audits of PBM's.

Manages occupational disease cases where an extensive knowledge of the Workers' Compensation Case Law is needed.

·        Makes initial determinations of causality in cases such as heart attack, multiple chemical sensitivity, severe hepatitis, HIV, and slow starting environmental illnesses.

Monitors the progress of cases.

PRINCIPAL MEDICAL CARE REPRESENTATIVE

 

Provides administrative supervision to Medical Care Representative staff of the assigned region.

 

 

 

 

 

 

Serves as a liaison between the SIF and local community service providers.

 

Makes determinations for the future utilization of outside services.

 

Maintains regional program statistics on all rehabilitation, radiology and full service vendors.

Oversees audits of PBM program.

Acts in place of the Chief Medical Care Representative when necessary.

CHIEF MEDICAL CARE REPRESENTATIVE

 

Establishes Statewide case management policies, procedures, and reference manuals and ensures staff compliance.

 

 

 

 

Provides expert assistance for home modification proposals.

 

 

 

Develops, prioritizes, implements and communicates goals and objectives.

 

 

 

 

Develops Statewide recruitment and retention plans for the Medical Care Representative staff.

 

 

 

Directly supervises Principal Medical Care Representatives and provides indirect supervision of the Supervising Medical Care Representatives.

 

Develops education and training standards, goals, and objectives for Medical Care Representative staff.

 

 

 

 

Minimum qualifications

Medical Care representative  

 

Must possess a current license and registration as a registered professional nurse in New York State AND three years of registered nursing experience in the following areas: rehabilitation, medical/surgical, public health, community health, visiting nursing, occupational health, utilization review, or review of medical records from hospitals for appropriate ICD 9 or 10/DRG/PAS/CPT* coding.

 

SUPERVISING MEDICAL CARE REPRESENTATIVE

One year of permanent competitive service as a Medical Care Representative, Grade 19.

 

PRINCIPAL MEDICAL CARE REPRESENTATIVE

Promotion:  one year of permanent competitive service as a Supervising Medical Care Representative, Grade 23.

Open Competitive:  Must possess a current license and registration as a registered professional nurse in New York State AND four years of registered nursing experience, which includes one year of supervision and two years of experience in any of the following areas:  rehabilitation, medical/surgical, public health, community health, utilization review, or review of medical records from hospitals for appropriate ICD 9 or 10/ DRG/PAS/CPT* coding. 

CHIEF MEDICAL CARE REPRESENTATIVE

 

Promotion: one year of permanent competitive service as a Principal Medical Care Representative, Grade 25.

 

Open Competitive:  Must possess a current license and registration as a registered professional nurse in New York State AND five years of registered nursing experience, which includes two years of supervision and three years in any of the following areas:  rehabilitation, medical/surgical, public health, community health, utilization review, or review of medical records from hospitals for appropriate ICD 9 or 10/ DRG/PAS/CPT * coding. 

 

*International Classification of Diseases-9th or 10th volume/Diagnostically Related Groups/Products of Ambulatory Surgery/Current Procedural Terminology.

 

Date:  2/05

 

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.