QUALITY CONTROL ANALYST MEDICAL ASSISTANCE AND HEALTH SERVICES
Quality Control Analyst Medical Assistance and Health Services is a state title in New Jersey's competitive civil service, which means the way in is an open exam rather than a direct appointment.
On paper it calls for a bachelor's degree, though the specification lets enough relevant experience stand in for the degree.
How to apply
This title is filled by competitive examination.
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See where to apply for this title →Official job specification
The text below is the official specification published by the New Jersey Civil Service Commission. The plain-language summary and analysis above are derived from it by NJ Civil Service Navigator. Source: the official specification page at NJ CSC.
Definition
Under direction of an Assistant Field Service Supervisor or other supervisor in the Division of Medical Assistance and Health Services, Department of Human Services, determines correctness of claims processed in the Medicaid Program by the contractors and the Bureau of Claims and Accounts; does other related duties as required.
Examples of work
Ascertains availability of third party coverage for use in providing medical care and its proper utilization May assist in the coordination/review of Medicaid quality control reviews at the contractors and the Bureau of Claims and Accounts for selected sample cases/claims. Compiles data for the timely preparation of various reports indicating accuracy of claims processing and utilization of third party liability benefits for the selected cases. Prepares correspondence required to obtain needed information to validate availability and the amounts of third party liability coverage. Conducts field visits to develop data needed to substantiate third party liability information. Prepares correspondence in the course of official duties. Prepares clear, sound, accurate, and informative reports on a timely basis. May assist in developing procedures for establishing/maintaining a quality control program for Medicaid claims in accord with federal regulations. Maintains liaison with staff and other interested groups. Maintains records and files. 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.
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 claims processing procedures. Knowledge of techniques used to gather, organize, and analyze data. Ability to read, interpret, and apply information on provisions of the NJ Medical Assistance and Health Services Program, and the rules/regulations/policies of the NJ Department of Human Services. Ability to read, interpret, and apply information on third party liability procedures and benefits. Ability to maintain liaison with interested individuals and groups. Ability to comprehend and interpret medical evidence in support of diagnoses. Ability to prepare accurate/comprehensive reports. Ability to maintain and interpret information on current state/federal legislation impacting program operations and services. Ability to conduct field visits and gather information and data. Ability to maintain records and files. Ability to prepare correspondence in the course of official duties. Ability 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 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 as long as they can perform essential functions of the job after reasonable accommodation is made to their known limitations. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible. CODES: 18/Pl8 - 62l9l RKR/cah 8/20/98
Note
The 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. Applicants must meet one of the following or a combination of both experience and education. Thirty (30) semester hour credits are equal to one (1) year of relevant experience. Five (5) years of professional experience in a public or private agency in work involving the evaluation of disability, medical, health, and/or public assistance claims. OR Possession of a bachelor's degree from an accredited college or university; and one (1) year of the above-mentioned professional experience. "Professional experience" refers to work that is creative, analytical, evaluative, and interpretive; requires a range and depth of specialized knowledge of the profession's principles, concepts, theories, and practices; and is performed with the authority to act according to one's own judgment and make accurate and informed decisions.