Health Care Compliance, #49170
Occupational Family: Health and Human Services
Pay Band Range: 4 - 6


Concept of Work

This Career Group provides career tracks for compliance specialists who are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, risk and safety, or operational practices. Responsibilities range from entry level professional to management. Employees inspecting medical facilities must be licensed as health care professionals.

Roles Comprising This Group

These roles describe the collective characteristics of the work performed by employees in the Health Care Compliance Career Group. The roles define the typical career paths for employees who pursue careers such as utilization review analysts, hospital quality assurance specialists, health care compliance specialists, and medical facility inspectors.

Although all of these occupations are compliance specialists, each warrants a separate career track. Each of these career paths requires different knowledge, skills, and abilities and would not naturally lead to the other for career progression. However, a role for each of these occupations represents different levels of work, or career progression. Career paths may exist within a single role, extend to other roles in this Career Group, or to roles in other occupationally related Career Groups.

PAY BAND

PRACTITIONER ROLES

ROLE CODE

MANAGEMENT ROLES

ROLE CODE

4

Health Care Compliance Specialist I

49171

 

5

Health Care Compliance Specialist II

49172

 

6

   

Health Care Compliance Manager

49173


Role Descriptions

These roles are distinguished based upon the Compensable Factors of Complexity, Results, and Accountability and are used for position classification. These factors should be used for classification and compensation analysis. Recruitment and selection standards must be based on knowledge, skills, and abilities as indicated in the Employee Work Profile.

Health Care Compliance Specialist I

Code: 49171

Pay Band: 4

SOC: 13-1041*

The Health Care Compliance Specialist I role provides career tracks for compliance specialists performing responsibilities ranging from entry level professional to first line supervisor. Employees audit, investigate, and inspect records, public and private operations, or facilities, to identify discrepancies in eligibility determinations, payment and billing calculations for individuals, third-party providers, or case records.

Health Care Compliance Specialist I

COMPLEXITY

  • Applies program rules and regulations in the resolution of human services programs.
  • Applies in-depth knowledge of one or more programs.
  • Frequent contact with service providers, recipients and their families, and representatives of other state and federal agencies on benefits and claims issues.
  • Employees conduct audits, inspections, or investigations of quality and utilization of services and may assist in promulgation review and revision of state licensure regulations operational guidelines.
  • May provide guidance to staff, clients, or others in private and public organizations.
  • May require knowledge of supervisory principles and practices.

RESULTS

  • Case, billing, pricing and redemption, and payment records are audited in accordance with applicable regulations and guidelines.
  • Discrepancies are identified and a report-of-findings or other communication is initiated.
  • Findings result in recommendations for, or provision of, corrective actions.

ACCOUNTABILITY

  • Directly accountable for the determination or detection of fraud, proper operation, and third party liability.
  • May lead or supervise staff.
  • Recommends licensure and certification of facilities.
  • Accountable for program policy interpretation.

 

Health Care Compliance Specialist II

Code: 49172

Pay Band: 5

SOC: 13-1041* and 29-9099*

The Health Care Compliance Specialist II role provides career tracks for compliance specialists that either: plan and administer all aspects of a quality assurance, health care compliance, and utilization review programs; or are licensed health care professionals conducting inspections of service delivery and service providers.

Health Care Compliance Specialist II

COMPLEXITY

  • Applies rules, regulations, and laws in administration of programs.
  • Renders decisions on unusual problems involving policy interpretation.
  • Frequent contact with health care providers, program administrators, and representatives from state and federal agencies, and other direct and indirect human service providers to confer on policy problems and request legal opinions.
  • May require knowledge of supervisory principles and practices.
  • Implements and oversees corrective actions.
  • May testify at administrative appeals and hearings.
  • Inspectors may be required to have licensure.

RESULTS

  • Approves and/or recommends corrective actions/plans that affect programmatic operations (e.g., changes to policies, or procedures)
  • Decisions may affect accreditation, licensure, and funding.

ACCOUNTABILITY

  • May lead or supervise staff.
  • Evaluates program effectiveness and compliance.
  • Develops administrative procedures.
  • Some positions approve and issue licenses and certifications.

 

Health Care Compliance Manager

Code: 49173

Pay Band: 6

SOC: 11-9111* and 11-9199*

The Health Care Compliance Manager role provides career tracks for managers who manage and direct quality assurance, health care compliance, and utilization review program operations. The work includes development, implementation, and evaluation of operational goals, objectives, policies, procedures, legislative recommendations, and operating budget.

Health Care Compliance Manager

COMPLEXITY

  • Directs a major organizational component of an agency, requiring management of staff, programs, and administrative functions.
  • Applies knowledge of general managerial and financial management principles and practices for purposes of conducting and assessing short and long-range planning.
  • Collaborates with state and federal officials on program compliance.
  • May require knowledge of forecasting and statistical methods and procedures.
  • May provide expert testimony for administrative, criminal and civil cases.
  • May require licensure in a health services occupation.

RESULTS

  • Decisions made affect program outcomes, service quality, accreditation, licensure, and funding.
  • Develops and implements business strategies and follows through with implementation.
  • Decisions affect public perception of the regulatory programsí effectiveness and expenditure of taxpayer dollars.

ACCOUNTABILITY

  • Leadership and supervision of staff.
  • Responsible for evaluating program effectiveness and ensuring compliance with State and Federal statutes.
  • Provides the highest level of consultation in the function.
  • Relies on expertise and judgment to determine, plan and accomplish goals.
  • May approve and issue licenses and certifications.

 

*Statistical Reporting

This Career Group includes, but is not limited to, those in the following Standard Occupational Classifications:

11-9111 Medical & Health Services Managers
11-9199 Managers, All Others
13-1041 Compliance Officers, Except Agriculture, Construction

 

New Effective Date: 11/01/01

History

Previous class titles (listed by new role title).

Health Care Compliance Specialist I

CLASS CODE

CLASS TITLE

GRADE

22501

Medical Assistance Program Representative

09

22503

Medical Assistance Operations Supervisor

09

46082

Social Services Quality Assurance Program Specialist

09

22181

WIC Program Representative

09

22062

Hospital Quality Assurance Coordinator

10

22081

Health Care Compliance Program Analyst

10

22502

Medical Assistance Program Representative Supervisor

10

41031

Utilization Review Analyst

10

22182

WIC Program Representative Senior

10

22064

Hospital Quality Assurance Assistant Director

11

22082

Health Care Compliance Program Analyst Senior

11

41032

Utilization Review Analyst Senior

11

46083

Social Services Quality Assurance Program Supervisor

11


Health Care Compliance Specialist II

CLASS CODE

CLASS TITLE

GRADE

22063

Hospital Quality Assurance Director

12

22083

Health Care Compliance Program Supervisor

12

22054

Medical Assistance Services Supervisor

12

41193

Medical Facilities Inspector

12

41162

Licensure/Certification Supervisor Senior

13

41196

Medical Facilities Inspection Supervisor

13


Health Care Compliance Manager

CLASS CODE

CLASS TITLE

GRADE

22084

Health Care Compliance Program Manager

15

41171

Licensure/Certification Program Manager

15

22507

Medicaid Operations Director

17