HEALTH CARE CONSULTANT

Definition

Under general direction of a supervisory official, performs the necessary research to prepare an analysis to set medical or medically related rates; performs the necessary research and analysis to develop plans, procedures, and contracts to oversee managed care or other medical models utilized by the state for their clients; does related work.

Examples of work

• Independently operate and performs complex tasks for a unit responsible for developing complex rates needed for managed care, other medical programs, and social programs.
• May perform the complex tasks of developing rates for managed care or other medical or social programs.
• Develops procedures for state oversight of contracted managed care programs or other medical or social programs.
• Compares Medicaid rates to commercial rates.
• Evaluates how capitation payments to Health Maintenance Organizations (HMO's) translate into reimbursement to providers.
• Develop state capitation data sources for design, development, and implementation of rates for specialized populations (developmentally disabled long-term care, behavioral health, and so forth.)
• Establish methodologies for monitoring and managing quality care and access to care by monitoring quality and access in a Medicaid managed care plan from both a staff and IPA perspective, setting up specific quality indicator standards (accessibility of services, following up on continuity of care, ensuring appropriateness and frequency of periodic screenings and identifying underutilization of services), creating systems to support and improve quality at the individual practice level.
• Establish plans and programs to better mainstream Medicaid clients by establishing, in a cooperative effort, ways for HMO's to deal with the special needs of Medicaid patients by: a) working to reduce barriers to preventive care through better member and physician education; b) implementing with our HMO partners effective outreach and hands-on case management for culturally diverse populations; c) working on client communications in an arena of low literacy and residential transiency; d) working to ensure a culturally competent provider network.
• Develops integration strategies for providers to encourage their movement into Medicaid managed care.
• Develops designs for better management information system utilization for tracking and monitoring HMO staff, patients, and other providers for cost and quality control.
• Analyzes and assesses comprehensive multi-disciplinary medical records to identify individual Medicaid recipient's health care programs and needs.
• Confers with nursing consultants, provides consultation, and in-service education to health care facilities for the purpose of maintaining and/or improving quality nursing services.
• Monitors development of required services, additional resources, training programs, and provides technical problem-solving advice to certified facilities.
• Analyzes care activities in Medicaid health facilities including but not limited to social services, patient activities, patient rights, psychosocial services, residential services, therapeutic recreation, services to families, and interventions which impact on patient health.
• Will be required to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.

Education

Graduation from an accredited college or university with a Bachelor's degree in Accounting, Economics, Finance, Health Care Administration, Hospital Administration, Public Administration, Public Health Administration, Mathematics, or Statistics.

Experience

Five (5) years of experience in the research, analysis, development, and/or administration of plans, procedures, and contracts pertaining to managed health care, and/or other medical or social programs.

License

Appointees will be required to possess a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform the essential duties of the position.

Knowledge, skills and abilities

• Knowledge of Federal and State applicable statutes, regulations, policies and procedures.
• Knowledge of the principles and practices of modern research methods, evaluation techniques, methodology of technical analyses, and the interpretation of results and findings.
• Knowledge of statistical techniques, modern laboratory automation systems methodology, procedures pertaining to the area of specific research, and methods of ensuring conformance therewith.
• Knowledge of the specialty area assigned, including knowledge of the most current analytical instrumentation utilized in specialty areas.
• Knowledge of appropriate federal regulations and procedural methods and requirements.
• Ability to plan, direct, and evaluate research activities.
• Ability to exercise good judgment in evaluating situations and making decisions concerning research and administrative problems.
• Ability to maintain cooperative working relationships with personnel assigned to other units within the department and divisions and with others concerned with the work of the research unit.
• Ability to prepare clear, scientifically sound, clinically accurate, informative reports of tests and other reports containing findings, conclusions, and recommendations.
• Ability to write scientific articles and take an active part in meetings and conferences.
• Ability to prepare official correspondence in connection with the research program.
• Ability to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
• Ability to read, write, speak, understand, and communicate in English sufficiently to perform the duties of this position. American Sign Language or Braille may also be considered as acceptable forms of communication.
• Persons with mental or physical disabilities are eligible if they can perform the essential functions of the job with or without reasonable accommodation. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.

Note

The definition and examples of work for this title are for illustrative purposes only. A particular position using this title may not perform all duties listed in this job specification. Conversely, all duties performed on the job may not be listed.

A Master's degree in any of the above disciplines may be substituted for one (1) year of experience.