New Job Chief Medical Care Specialist In Rhode Island

To be responsible for assisting the Director in the planning and administration of a state-wide medical care program for eligible recipients of medical assistance (under the provisions of Title XIX of the Federal Social Security Act and appropriate State Statues) by assisting in such activities as:

the development and revision of rules, regulations, procedures and fee and cost standards governing the procurement and payment of medical services and supplies; conferences with appropriate professional groups, representatives of state medical and dental societies, etc., and vendors of medical, dental and other supplies for the purpose of effecting common understanding and general acceptance thereon and to reconcile discrepancies and irregularities as well as continuous or aggravated violations involving charges, rules and regulations, standards or procedures of such medical care program; the preparation of manuals based on such rules, regulations, procedures and fee and cost standards for the benefit of members of the medical, dental and other professions as well as vendors of medical, dental or other supplies in order to assist them in preparing and submitting bills for payment to the State for such medical services and/or supplies; and reviewing and approving all requests for payment of medical services and supplies provided eligible recipients of medical assistance upon determination that the medical services and supplies provided and the amounts charged are allowable under the medical care program.

To participate in a program or orientation, information and consultation designed to acquaint social welfare staff, local directors of public welfare, professional consultants, advisory committees and other interested parties with the philosophy, objectives and operations of the public assistance medical care program.
To assist in the determinations of unmet needs in the medical care program and to make recommendations to establish a preliminary program to fulfill such unmet needs.
To assist the Medical Care Program Director in community activity in medical care and health planning.
To collect various statistical data relative to the medical care program and prepare reports on the various trends involving such medical care.
To relieve the Medical Care Program Director of administrative details relative to the operation of the medical care program.
To do related work as required.

KNOWLEDGES, SKILLS AND CAPACITIES: A thorough knowledge of the State plan for medical assistance; a working knowledge of approved principles and practices of public health medical care administration and the ability to apply such knowledge by assisting a superior in the planning and administration of a state-wide medical care program; a familiarity with the practices and procedures of hospitals, nursing and convalescent homes and other institutions providing medical care and treatment; the ability to assist a superior by meeting with members of the medical and dental professions, social welfare staff and other interested parties for the purpose of explaining the philosophy, objectives and operations of the public assistance medical care program and to provide consultative services and advice as required; the ability to collect information relative to a medical care program and prepare various trend data for statistical purposes; the ability to relieve a superior of administrative details; the ability to assist in the planning, supervision and review of the work of a professional and clerical staff; the ability to establish and maintain effective working relationships with professional groups, community and other public and private agencies; and related capacities and abilities.

EDUCATION AND EXPERIENCE:

Education: Such as may have been gained through: graduation from a college of recognized standing and possession of a master’s degree from an accredited institution of higher education in the field of Medical Care Administration, Public Administration, Social Work, Public Health Administration, Business Administration.
Experience: Such as may have been gained through: employment as a Senior Medical Care Specialist, or in a responsible supervising position in the fields of Public Health, Medical Care Administration, Public Administration or Social Work.
Or, any combination of education and experience that shall be substantially equivalent to the above education and experience.

The Chief Medical Care Specialist will serve as the program manager overseeing the overall day to day operations, planning and process improvement for the work of the DHS LTSS Clinical Team

The DHS LTSS Clinical Team is vital to the Clinical Eligibility Determination for a variety of programs under Medicaid and LTSS serving customers of all ages and across Medicaid populations.

The person in this role will oversee the process for Nursing Home Level of Care (LOC) Determination for customers in Institution and Home and Community Based Services (HCBS); Assessments and Prior Authorization for Private Duty Nursing (PDN), Pediatric Nursing and Katie Beckett; as well as MART (Medial Assistance Review Team) determinations.

The person in this position will recommend change in policy and practice, and actively involved in the planning, implementation, developing and updating processes to address the evolving trends in the health care needs of Medicaid and LTSS beneficiaries.

This position is also responsible for assuring work is performed in an efficient and effective manner to streamline access to program eligibility and services utilization.

The Chief Medical Care Specialist position requires someone with independence in effectively driving the work of the team as well as the ability to foster strong collaboration with all relevant stakeholders including providers, families, and inter-agency partners.

Required Qualifications:

Candidate must hold a current, valid Rhode Island Registered Nurse license, or if licensed in another state, apply for and be granted a Rhode Island Registered Nurse license by endorsement within one-hundred and twenty (120) days from date of hire. Applicant must also be in good standing with Rhode Island, the issuing state, and the Department of Health.

Preferred qualifications:

• Extensive Clinical expertise and practice experience with evaluating and assessing clinical needs of customers with long- term care services, medical, clinical, and behavioral health needs.
• Program management, supervisory and leadership experience in coaching and leading others to achieve and grow.
• Culturally competent, fosters diversity, equity, and inclusion.
• Excellent written and oral communications skills.
• Knowledge of Medicaid LTSS eligibility, enrollment and program rules.
• Knowledge and experience with long term care community supports and services.
• Comfortable with learning and utilizing a variety of computer systems including RI Bridges, CSM, Microsoft Office, MDS, Access Databases, MMIS, Wellsky and other technical tools.