|Class Title:||BENEFITS ADMIN EXAMINER|
|Bargaining Unit:||Use for all Job Titles|
Education and Experience: Graduation from an accredited college or university with a bachelor’s degree in accounting, statistics, or information systems and experience equivalent to three years of auditing, quality assurance, or data analytics and aggregation work.
Substitution of Education for Experience: Graduate course work from an accredited college or university in accounting, statistics, or information systems may substitute for the required experience on a year-for-year basis to a maximum of two years (e.g., an additional 36 graduate quarter hours in one or a combination of the above listed fields may substitute for one year of the required experience).
Substitution of Experience for Education: None
Other Requirements: Necessary Special Qualifications: None
Examination Method: Education and Experience, 100%, for Preferred Service positions.
Job Overview: Summary: Under general supervision, performs professional health data analytic and research work of considerable difficulty and performs related work as required.
Distinguishing Features: An employee in this class performs independent research and health data analytic functions based on industry best practices.
Work Activities: Getting Information
- Gathers and tracks health related data to compile datasets to ensure the division meets its goals, objectives, and reporting responsibilities.
- Develops and conducts surveys to collect data from external agencies, analyze data and report findings to management.
- Reviews existing data bases to ascertain the accuracy, existence and availability of needed data variables or data elements.
- Conducts secondary research such as health related professional publications and internet research for historical information, trend analysis, and best practices to detect errors, fraud, waste, and abuse.
- Contacts sources to obtain additional information to ensure accurate and complete data as needed.
Monitor Processes, Materials, or Surroundings
- Generates and monitors reports on variables that may affect the health status of state sponsored health plans members.
- Monitors workflow and health claims data to ensure the quality of data meets vendor claims data requirements.
- Monitors health claims data to detect deviations from trends or expectations.
Identifying Objects, Actions, and Events
- Identifies the relevant data sources, variables, tables and literature to complete the project.
- Determines methodology and attributes to be tested based on assigned review program.
- Identifies sample population to be reviewed based on objectives.
- Identifies work priorities to ensure the most important work is completed first based on work experience, supervisor guidance, and departmental, state and federal laws, rules, regulations, and guidelines.
Judging the Quality of Things, Services, or People
- Generates risk assessments to be evaluated by assigned supervisor related to reviews to be conducted and programmatic areas.
- Assesses datasets in order to ensure that data quality standards are met.
- Conducts and assists with special assignments and investigations as required.
- Writes reports in accordance with departmental guidelines and at an appropriate level of audience understanding while ensuring narrative is written so that all confidential information of those involved in the study is protected.
- Prepares draft reviews narrative reports from work paper summaries under general direction, to document review results, clearly communicate results and make recommendations for corrective actions.
- Reviews reports to check for errors and makes sure corrections have been made to ensure accuracy.
- Writes reports to explain reviews which have been conducted; finalizes formatted documents for electronic and/or other means of distribution.
- Prepares work papers and supporting documentation from a review of records and other resources to identify legal, financial, compliance, and/or administrative problems or discrepancies under general direction.
- Indexes work papers and supporting documentation from a review of records and other resources to identify legal, financial, compliance, and/or administrative problems or discrepancies under general direction.
- Documents and maintains procedural information in written or electronic form for reference within the program or manuals.
Evaluating Information to Determine Compliance with Standards
- Plans, organizes, and conducts operational reviews to evaluate the efficiency and effectiveness of various programs.
- Uses relevant information and individual judgment to evaluate claims information and determine compliance with Plan documents.
- Plans, organizes, and conducts compliance reviews of division vendors and participatory agencies to determine statutory compliance.
Analyzing Data or Information
- Develops methodology pertinent to research project (i.e., determines variables to be studied and sample size, discusses statistically valid data collection methods, sets a time-line for the components of the study, and determines how the results of a study will be distributed).
- Uses computer software (i.e., Access, Excel, ACL, or other specified software related to area of study) to analyze data.
- Interprets results of analytical procedures to determine relationships among the data as well as implications for findings.
- Compares results of analytical procedures to previous results to determine changes over time.
Making Decisions and Solving Problems
- Interprets health claims data to determine appropriate recommendations to management.
- Assists with the identification and resolution of problems related to processes or performance.
- Meets with supervisor and/or subject matter experts to discuss the most efficient and effective approach to conducting analytical reviews.
- Develops and implements end user appropriate electronic spreadsheets, charts, and graphs for use to facilitate analysis.
- Designs review work programs as necessary to fit parameters of the assigned review.
- Brainstorms workflow and process improvements with co-workers, and assigned supervisor to enhance workplace efficiency
- Makes suggestions to assigned supervisor to improve the review process and program.
Updating and Using Relevant Knowledge
- Attends professional development and continuing education courses as required.
- Attends department specific in-service training as required to enhance personal development.
- Attends department specific in-service training, out-service training, conferences, webinars; maintains required proficiency in the field and applies new knowledge to job.
Scheduling Work and Activities
- Schedules routine projects to accommodate high priority assignments in order to meet necessary deadlines.
- Coordinates the work and activities with others to accomplish program goals and objectives as needed.
- Schedules meetings with internal and external parties to meet review or project objectives.
- Schedules staff meetings as required to facilitate interpersonal and inter-departmental goal achievement.
- Schedules personal vacation and requests for time off to ensure proper coverage.
Organizing, Planning, & Prioritizing Work
- Utilizes metrics to assess the importance of progress of programs, activities or data.
- Manages long term projects to ensure timely completion of project milestones.
- Cross trains with co-workers in assigned job duties to ensure continuity of operations.
- Prioritizes daily tasks to meet deadlines and facilitate efficient task completion.
Interacting with Computers
- Enters or imports collected claims data into appropriate database and fields to analyze data.
- Utilizes software applications to perform analysis.
- Utilizes computer software to transfer results into a multimedia format and graphic representations for presentation purposes.
- Proofreads entered data to verify accuracy and completeness.
- Assesses software application packages for potential use with datasets.
- Creates and maintains back-up copies of data for recovery purposes.
- Utilizes electronic mail and other devices to facilitate communication and internal and external customers.
- Enters time and leave requests and travel and expense reports in electronic database as required.
Interpreting the Meaning of Information for Others
- Utilizes appropriate metrics for describing the problem or issues and communicates the findings to stakeholders.
- Interprets health claims data for management in response to requests for information.
- Interprets departmental policies, procedures, rules, and regulations for internal and external customers.
- Makes users aware of the accuracy, scope, limitations, and de-limitations of the data and metrics.
Communicating with Supervisors, Peers, or Subordinates
- Provides timely information to supervisors and co-workers in a clear and accurate manner.
- Communicates with officials at higher levels on situations requiring cooperation and explanation of the services and activities of the agency.
- Responds to inquiries for information from upper management personnel.
- Communicates with supervisors and co-workers using multiple media to assist with problem solving and resolution.
- Notifies management of systemic complaints and problems to obtain resolution.
Communicating with Persons Outside Organization
- Plans and develops information that is communicated to insurance committee members and other interested parties.
- Communicates with other governmental agencies, vendors, and educational institutions to collect or provide data, collaborate, and provide analysis.
- Communicates with vendors and other outside entities to exchange and/or obtain information.
Establishing and Maintaining Interpersonal Relationships
- Provides a customer focused work environment to internal and external customers to ensure timely and accurate delivery of services.
- Maintains professional working relationships with peers and with upper management to ensure smooth and effective team operations
- Conducts themselves in a professional manner during the course of assigned duties.
- Establishes and maintains a variety of personal contacts with departmental officials, agency representatives, attorneys, associates, supervisory staff and others to foster good will and enhance trust.
- Establishes meaningful working relationships with co-workers to ensure effective goal achievement.
- Communicates with internal and external customers in a friendly and courteous manner to promote healthy relationships and provide exceptional customer service.
Developing and Building Teams
- Assists team members with task performance to encourage cooperation.
- Develops and participates in team building activities with supervisor and co-workers.
Competencies (KSA’s): Competencies:
1. Decision Quality
2. Learning on the Fly
3. Problem Solving
4. Technical Learning
5. Process Management
6. Comfort Around Higher Management
7. Written Communications
8. Customer Focus
9. Ethics and Values
10. Integrity and Trust
1. Intermediate Knowledge of Computers and Software
2. Intermediate Knowledge of Mathematics and Algebra
3. Customer Service
4. Knowledge of Health Claims and Procedure Codes
5. Knowledge of Quality Assurance Standards
1. Active Listening
2. Critical Thinking
3. Reading Comprehension
8. Service Orientation
9. Complex Problem Solving
10. Judgment and Decision Making
11. Systems Evaluation
1. Deductive Reasoning
2. Flexibility of Closure
3. Inductive Reasoning
4. Information Ordering
5. Mathematical Reasoning
6. Oral Comprehension
7. Oral Expression
9. Problem Sensitivity
10. Time Sharing
11. Written Comprehension
12. Written Expression
Tools and Equipment Used:
- Personal Computer
- Fax Machine