Medicaid Specialist

  • Medicaid Specialist
  • What will I be doing?
  • Do I qualify?
  • Can I be successful?
  • Benefits
  • How do I apply?
Class Number: 
5342
Exam Components: 
Rating of Education & Experience, 100%
Annual Salary Range:
$36,924.00 – $52,116.00
Twice-a-Month Salary Range:
$1,538.50 – $2,171.50
Pay Grade: 
A23

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Definition

This is professional work developing, evaluating, and monitoring the operation of assigned specialized area of the Medicaid Program within the Missouri Department of Social Services.

Job Duties

Develops, from an analysis of collected data, Medicaid policies, procedures, and task statements to reduce program errors, improve program efficiency, and ensure conformance to laws and regulations.

Develops and explains policies and procedures; detects program abuse and inappropriate usage, including Medicaid eligibility issues; and provides technical assistance to the Medicaid Unit Supervisor and/or other staff.

Identifies program abuse cases and pursues recovery or correction of provider overpayments, other payers' liability, system errors, multiple billings, unnecessary practices, suspected fraud, ineffective procedures and policies, and other factors contributing to inappropriate Medicaid Program usage or inefficient use of Medicaid resources.

Coordinates special programs and projects; evaluates and prepares reports, procedures, and regulations.

Conducts reviews of Medicaid providers for compliance to program regulations and procedures; provides consultation regarding program procedures.

Responds to inquiries from providers, recipients, medical consultants, public officials, the public, and others regarding eligibility, policies and procedures, pricing and fee structure, questionable claims, and other areas related to the Medicaid Program.

Evaluates Medicaid bulletins, forms, manual revisions, and fee schedules to ensure that information is clear, logical, and conforms to existing policy, procedures, and regulations.

Researches and analyzes Medicaid data collected from recipients, providers, manuals, and other sources to answer questions and resolve problems.

Confers with medical consultants, representatives of governmental agencies and the fiscal agent, representatives of professional organizations, and others to provide instruction, obtain advice, and coordinate policies and procedures.

Initiates computer data matching with third party payers and other entities to ensure cost effective utilization of the Medicaid Program.

Supervises and trains technical and clerical staff.

Performs work with independence and initiative; receives general administrative direction for conformance to procedures and attainment of objectives.

Performs other related work as assigned.

Areas of Interest: 
Social Service, Public Welfare & Mental Health

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(The following minimum qualifications will determine merit system eligibility.  Allowable experience and education substitutions are provided in italics below the corresponding minimum qualification statement; no other substitutions will be permitted.  These minimum qualifications may also be used to evaluate applicants for Missouri Uniform Classification and Pay System positions not requiring selection from merit registers.)

Two or more years of experience as a Medicaid Technician, Medicaid Pharmaceutical Technician, or Correspondence and Information Specialist I within a Medicaid Program with the Missouri Department of Social Services; and possession of a high school diploma or proof of high school equivalency.

OR

Bachelor's degree from an accredited college or university with a minimum of 15 earned credit hours in one or a combination of the following: Public, Business, or Health Care Administration; Nursing; Health Sciences; Medical Technology; Social Work; Finance; Accounting; or a closely related field; and,

Two or more years of professional or technical experience in one or more of the following fields: health care provider relations; medical insurance claims processing; Medicaid Program regulations, operations, or activities; health care regulations development/enforcement; statistical or fiscal record keeping and/or analysis; or closely related work.

(24 earned graduate credit hours from an accredited college or university in the specified areas may substitute for one year of the required experience.)

(Additional qualifying experience may substitute on a year-for-year basis for deficiencies in the required education.)

OR

Bachelor's degree from an accredited college or university with a minimum of 15 earned credit hours in one or a combination of the following: Public, Business, or Health Care Administration; Nursing; Health Sciences; Medical Technology; Social Work; Finance; Accounting; or a closely related field; and,

Two or more years of professional supervisory or consultative experience in financial eligibility assessment.

(24 earned graduate credit hours from an accredited college or university in the specified areas may substitute for one year of the required experience.)

(Additional qualifying experience may substitute on a year-for-year basis for deficiencies in the required education.)

Please note that documentation that supports your eligibility (i.e. transcripts, employment records, etc.) may be required at any time during the application and hiring process. If you do not possess the minimum qualifications, please consider one of many other employment opportunities with the State of Missouri.

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Key Skills

Do you possess the key skills which are considered essential for successful employment in this classification?

Comprehensive knowledge of the procedures used in initiating, processing, and evaluating medical claims.

Comprehensive knowledge of federal and state laws, rules, regulations, and procedures governing the operation of the Title XIX Medicaid Program.

Comprehensive knowledge of the preparation, location, and use of computerized information systems, reference manuals, reporting systems, and other related resource documents and files used in the operation of the Medicaid Program.

Comprehensive knowledge of methods and techniques used in preparing technical reports and procedure manuals.

Comprehensive knowledge of procedures and techniques used in collecting, organizing, and evaluating simple statistical and financial data.

Intermediate knowledge of supervisory principles and techniques.

Ability to analyze and evaluate a variety of laws, rules, regulations, procedures, and technical data pertaining to the Medicaid Program; make logical inferences; and draw sound conclusions based on this data.

Ability to communicate effectively.

Ability to work effectively with a variety of technical and professional staff in the Medicaid field.

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The following link will provide you with general information about State of Missouri employee benefits.

View benefits

View Class Specification Document