Medical Certification Specialist 2

Supplemental Information Helping people, changing lives through education, prevention, intervention, and treatment in an effort to enhance quality of life.
This vacancy is located at SCLHSA's Developmental Disabilities office located in Houma, LA.
This position is an advanced specialized medical position within the South Central Louisiana Human Services Authority/Developmental Disabilities/Waiver Supports and Services Office.
Incumbent performs advanced level duties involving reviews, interpretation and decisions of medical certification/eligibility for Medicaid expenditures for individuals seeking Home and Community Based Waiver Services (HCBWS in accordance with federal and state Medicaid guidelines.
Incumbent must be knowledgeable of policies/procedures in accordance with the four separate HCBWS currently being administered in Louisiana: New Opportunities Waiver, Children’s Choice Waiver Supports Waiver, and Residential Options Waiver.
Incumbent also uses highly developed medical and professional skills to provide technical assistance, consultative services, programmatic oversight and direction to support coordination agencies as well as services agencies regarding quality of services, compliance with Medicaid guidelines for waiver certification, and responsible delivery of services.
Incumbent must be knowledgeable and familiar with region-wide resources in order to refer individuals and/or service agencies to such for assistance.
Incumbent travels throughout the region to visit in recipient homes to conduct interviews with recipient and their families regarding service planning, quality of service delivery, verification of choice in waiver services and their selection of providers, to ensure they exercised their freedom of choice in service and provider selection, and to provide feedback recommendations to service agencies and assist in negotiation between recipients and service delivery entities.
This position requires a good working relationship with a variety of other state agencies in order to collaborate services across many settings.
It requires knowledge of the various requirements, policies, etc.
of each agency.
Agencies include but are not limited to regional Developmental Disability (DD) offices, Families Helping Families, Louisiana Rehabilitation Services, Office of Community Services (OCS and Child Protection), Adult Protective Services (APS), and Elderly Protective Services (EPS).
The incumbent of this position performs duties within the geographical area of the region.
NOTE REGARDING ADVERTISED PAY: The actual starting salary depends on the education and experience of the selected applicant.
No Civil test score is required in order to be considered for this vacancy.
Applicants are responsible for checking the status of their application to determine where they are in the recruitment process.
Further status message information is located under the Information section of the Current Job Opportunities page.
*Resumes WILL NOT be accepted in lieu of completed education and experience sections on your application.
Applications may be rejected if incomplete.
* For further information about this vacancy contact: Macy Comeaux HR Director Macy.
Richard@la.
gov 985-876-8876 Qualifications MINIMUM QUALIFICATIONS: A baccalaureate degree plus three years of professional level experience in hospital or nursing home administration, public health administration, social services, nursing, pharmacy, dietetics/nutrition, physical therapy, occupational therapy, medical technology, or surveying and/or assessing health or social service programs or facilities for compliance with state and federal regulations.
SUBSTITUTIONS: A current valid Louisiana license in one of the qualifying fields will substitute for the required baccalaureate degree.
A master's degree in hospital administration, nursing home administration, public health administration, social work, nursing, pharmacy, dietetics, nutrition, physical therapy, occupational therapy, or medical technology will substitute for a maximum of one year of the required experience.
NOTE: Any college hours or degree must be from an accredited college or university.
NOTE: A current valid Louisiana license in an individual field may be required for some positions.
NECESSARY SPECIAL REQUIREMENT: FOR HEALTH STANDARDS SECTION JOBS ONLY Federal regulations may mandate additional requirements prior to appointment.
Job Concepts FUNCTION OF WORK: To conduct surveys and/or assessments to verify that the services provided to individuals by providers, facilities, waivers, and/or long term care programs are in compliance with federal certification, state regulations, and established state standards.
LEVEL OF WORK: Advanced.
SUPERVISION RECEIVED: Broad direction from Medical Certification Supervisor or other higher level agency administrator.
SUPERVISION EXERCISED: None.
LOCATION OF WORK: Department of Health and Hospitals.
JOB DISTINCTIONS: Differs from Medical Certification Specialist 1 by the possession of the Centers for Medicare and Medicaid Services certification and by the level of independence exercised in carrying out work responsibilities.
Differs from Medical Certification Supervisor by the absence of supervisory responsibilities.
Examples of Work 75% Certification Duties/Activities: Receives and reviews in detail all components of the individual’s initial comprehensive plan of care for approval of home and community based services making a medical eligibility determination decision within 10 business days of receipt as identified in federal and state guidelines.
Minimum components of the plan of care are: Statement of Approval and any supporting documentation from the regional Developmental Disabilities (DD) office verifying the person meets the legal definition of having a DD and is eligible to participate in the Developmental Disabilities Services System; Medicaid Form 148 (Information regarding Admissions/Discharge/Status Changes); 90L (certifying the person meets the level of care criteria for receiving waiver services and that HCBWS are adequate to meet the person’s needs, all diagnoses are listed, physical status, medications, etc.
are noted); Behavior Support Plan if needed; Provider’s back up staffing plan/Emergency Evacuation Preparedness Information; Waiver Rights & Responsibilities statement; Freedom of choice for Support Coordination and Service Agency; as well as Comprehensive Plan of Care outlining all information regarding person’s disability, social supports, medical/psychiatric/psychological information, hours of staff support requested, and financial costs of services as requested; Supports Intensity Scale (SIS) if applicable; LA Plus if applicable; Inventory for Client and Agency Planning (ICAP) if applicable; and Individual Review (ISR) Protocol.
Evaluates overall effectiveness of recipient’s plan, ensuring personal outcomes and person centered goals are identified appropriately within each plan and evaluates how supports will ensure the individual’s health and safety in the community setting.
Reviews CPOC budget for accuracy and to assure fiscal responsibility in determining if budget appropriately meets the individual’s needs.
Collaborates with non-medical Regional Office Staff, Support Coordinators, and Service Providers regarding complex, medically involved waiver individuals, ensuring health and safety measure are met.
Communicates with support coordinator on any errors/missing information that can be immediately corrected.
Returns incomplete or non-approvable plans to support coordination agency and communicates the need regarding further information and why plan is deemed incomplete or is not approvable.
Gives technical assistance to support coordination agencies regarding methods of improving the incomplete plan.
May also communicate with service agency regarding need for further information.
Obtains information from review of records, applicant/recipient interview, and personal observation during home visits to make a determination of medical eligibility for certification into a waver service program.
For all initial plans determined to be complete, incumbent makes a home visit to recipient prior to certification decision to assess the effectiveness and quality of the planning process, and to ensure that personal goals and outcomes are appropriate and were addressed.
This visit is also used to determine if the recipient’s living conditions are adequate and if HCBWS services are sufficient to ensure the recipient’s health and safety.
Any findings/concerns are discussed with the support coordinator.
If there are any concerns about the living conditions that cannot be immediately resolved or any serious health and safety issues, it is discussed with the support coordinator and forwarded to the appropriate agency (APS, OCS, EPS).
Upon receipt of complete plan and after mandated home visit for initial requests, incumbent makes a determination of medical eligibility for certification for waiver services within 10 days of receipt and uploads Form 142: Notice of Medical Certification to the Louisiana Medicaid Eligibility Determination System (LaMeds) system.
Medicaid determines if the person meets financial eligibility to receive HCBWS.
Incumbent tracks status through approval of long-term personal care Medicaid in LaMeds.
Upon receipt of Form 18-W (Medicaid Notice of Decision) from Medicaid Office, incumbent completes Form 51-NH (Waiver Services Admission & Charge Form) and sends the 148 W linkage, 51-NH, the Decision Notice and date of Home Certification Visit to the DHH data contractor, Statistical Resources Inc.
, for Prior Authorization of services and to the Support Coordination agency.
Incumbent approves the Electronic Plan of Care in the Louisiana Statistical Resources System (LASRS).
Upon receipt of Exception Request Form and documentation, incumbent reviews and completes Exception Request Decision form to be presented to the Regional Office Committee for review and to determine if recipient is eligible for the next tiered waiver.
In the event the recipient requires the NOW tier, State Office Review Referral will be completed and submitted with all necessary documentation and assessments to State Office for determination of recipient’s eligibility for the NOW tier.
Requests additional information from the support coordination agency and services providers as needed to complete the request prior to committee review.
If request is approvable, Exception Decision Form is submitted to SRI and new linkage will be generated for appropriate tiered waiver.
Consults with regional administrative staff as needed and State Office Review Panel at OCDD state office as directed by regional administrative staff for those plans that have particularly challenging issues and require a more comprehensive/in-depth review.
Preparing info for committee review includes, for example, reviewing three months of daily progress notes, reviewing medical information and/or Critical Incident Reports.
Presenting the information for review to those entities in a comprehensive-fact based communication.
On an annual basis, reviews service plans submitted for annual recertification.
Minimum information required for recertification may include the same documents as listed for initial requests.
Reviews and makes determination for continuation of waiver services at least 10 days prior to CPOC expiration date, as outlined in state and federal Medicaid policy and procedures, following same procedure as initial plan certification but without the home visit.
Incumbent receives requests for changes to the recipient’s service plan by the submittal of emergency and non-emergency service plan revisions.
Revisions can involve requests for additional service hours, change of providers, or requests for use of environmental medication funds.
All revisions require justification for the request.
Communicates with support coordination as well as service agencies regarding revision submitted, requesting additional information to support request as needed.
If a request is approvable, it is then forwarded to SRI and the support coordination agency.
If not, it is returned to the support coordinator.
For annual redetermination or revision request, incumbent may negotiate, offer technical assistance and facilitate communication among and between service recipient, support coordinator and service agency.
This requires professional communication skills exercising judgment and collaborative skills to achieve outcomes that are satisfactory for all parties involved.
Upon receipt of approvable information for annual recertification request and revision request, incumbent provides approval notice to Statistical Resources Inc.
and Support Coordination Agency.
Prepares information and summary of evidence for appeals as requested by consumers and families who do not agree with decision of agency.
This requires submitting the summary of evidence gathered as prepared by research of policy and presentation of documents to support the agency decision.
The summary is submitted within a set deadline to the Bureau of Appeals.
Incumbent participates in the appeal hearing that is conducted in person or by phone with the DHH Bureau of Appeals Administrative Law judge.
This participation includes presentation of evidence previously prepared and submitted by incumbent that outlines reason for decisions and agency policy on such.
20% Non-Certification Activities/Duties: Incumbent is routinely called upon to assist individuals, service agencies, and support coordinators in determining a course of action within given situation to ensure the health and safety as well as personal choices of individuals receiving services.
Particular to this assistance are the situations regarding individuals transitioning from Supports and Service Centers into home and community based services.
These individuals typically present with more challenges and support needs due to their increased level of disability that requires in depth knowledge of supports planning for success.
Other situations may include when an individual enters the Stabilization Units at Supports and Services Centers.
Waiver staff are involved in meetings to track progress, monitor length of stay, and ensure all health and safety issues are addressed before discharge.
Incumbent follows up as assigned by administrative staff to communicate and receive information regarding critical incident reports that have been submitted electronically into the Statewide Incident Management System (SIMS) by support coordination and direct service provider agencies.
Incumbent collaborates with support coordinators to assist them to seek in-depth solutions to situations presented with critical incident reports.
Incumbent works closely with APS/EPS/OCS as they conduct any investigations involving waiver recipients.
After the investigation is complete, waiver staff ensures that all recommendations are implemented.
Incumbent may advise support coordinator in methods of planning supports and communicating with service agencies to prevent future critical incidents.
High Risk cases which include NOW participants with a Resource Allocation level of 4, 5, or 6 require a more in-depth involvement by incumbent in planning and may require active participation in the assessment and planning process; including attending team meetings, ongoing interaction with team members and possible involvement with the Community Support Team and/or judicial system.
Other High Risk cases will include those individuals who meet criteria for Non-Consensual Sexual Behaviors (NSB) committee review.
Incumbent will prepare NSB referral documentation, gather all necessary documentation from SCA and DSP agencies for quarterly NSB committee review meetings and participate in the quarterly NSB committee review meetings.
Incumbent receives investigations and resolves complaints at the request of a supervisor or Quality Assurance Coordinator.
Incumbent completes/processes appropriate paperwork for waiver participants transferring into and out of region and paperwork for discharges/closures/inactive status.
Incumbent has routine interaction with Statistical Resources, Inc.
to review and respond to problem sheets, Prior Authorization issues, and Waiver registry issues.
Makes unannounced visits to recipients’ homes to conduct health and safety checks as needed.
If there are any findings, a statement of deficiencies is issued to the provider detailing what was found.
The provider then submits a plan of corrective action to address them.
Depending on the nature of the findings, a referral may need to be made to the proper entity such as: Program Integrity for suspected fraud, APS/OCS/EPS for any suspected abuse, neglect, exploitation, etc.
Cooperates and assist all agencies in their investigations.
At times, either due to the individual’s choice or through involuntary methods, a recipient’s waiver may be closed.
This is done following the discharge criteria and procedures as outline in each waiver’s rule and manual.
5% Other Duties: Has routine and regular contact with non-waiver participants and other agency/ entities regarding definition of home and community based services, promotion of such services, application process for services, and status of service requests.
May be called upon to present information regarding the program to other agencies for education purposes.
May represent SCLHSA at various meetings/trainings to share information about and encourage use of different waiver programs.
Participate in staff and unit meetings as a necessary and as requested by unit supervisor.
Uses a variety of computer programs and web based systems that are specific to the Waiver service delivery system.
These systems are used to verify someone’s status of a service request, to verify service provider’s qualifications and current enrollment in Medicaid, to track Critical Incident Reports, and to verify if prior authorizations have been issued for service delivery.
Participates in individual meetings with supervisors as necessary to keep him/her abreast of situations and workload.
Participates in professional and educational trainings to maintain and improve professional skills.
Participates as necessary in emergency preparedness training and activities to be prepared in the case of such situations.
Performs additional duties as assigned by supervisor.