Under direction of Industrial Rehabilitation Supervisor & as member of Operational Policy, Analytics and Compliance (OPAC) division’s Compliance & Performance Monitoring unit (e.g. case management & nursing staff), serves as vocational resource & provides technical direction to other Compliance staff in performance of reviews related to provision of vocational rehabilitation (rehab) services & their associated costs: serves as primary vocational reviewer for Compliance, whose staff conduct routine & complex reviews of BWC vocational & medical processes (e.g. travels statewide, monitors & evaluates performance of Managed Care Organizations [MCOs] for Policy compliance); provides ongoing training to BWC’s & MCOs’ case management staff on most complex & difficult cases; provides technical direction to private rehab providers, MCOs & BWC’s Field Operations staff; provides technical support & assistance (e.g. regarding vocational terminology & benchmarking, bill coding & procedures, researching reasons for inaccurate vocational information, training in review process); advises MCO staff on compliance review process & answers questions regarding performance reviews, actions & follow-up; serves as liaison between senior Compliance officers & other Compliance staff to coordinate discussions with entities under review; gathers & synthesizes information for monitoring compliance of medical & vocational providers & MCOs; consults & collaborates with internal & external subject matter experts & resources for research, investigation & analysis of bill payment practices & for purposes of benchmarking industry best practices; reviews MCO contracts, provider agreements & BWC policies& procedures to identify MCOs’ medical & vocational contractual requirements; synthesizes & analyzes compliance review objectives to determine selection of files to obtain data elements necessary for true & accurate assessments; researches & analyzes selected medical & vocational activities & associated billing (e.g. statistical data) to document compliance with BWC Policy & Procedures; determines MCOs’ & medical/vocational providers’ compliance with applicable contracts, rules, regulations, policies & procedures & identifies areas of poor performance, opportunities for improvement & instances of provider non-compliance; summarizes compliance findings (e.g. prepares flowcharts & workflows, identifies procedures for MCO/BWC control points & makes recommendations to strengthen identified weaknesses); reviews documents for authorization, accuracy & proper recording; researches reasons for inaccurate case management information; creates work-paper documentation & spreadsheets for review completion; summarizes & verifies results of Compliance staff work & resolves issues & discrepancies; documents all steps taken during each compliance review; attends meetings to discuss compliance findings with applicable parties; maintains tracking system of CARs completed; produces reports for supervisor on compliance projects statuses. Makes recommendations for compliance reviews, follow-up & re-testing of MCOs’ & BWC’s processes & contracts (Rehab Services Commission [RSC]) to ensure compliance of policy & reevaluations as appropriate: prepares CAR reports (i.e. recommendations to improve adherence of contractual requirements, BWC rules & laws, customer service & to prevent financial loss); documents, tracks & monitors results of regulation analysis & action steps based on analysis results; travels to off-site locations to follow up on progress of required action steps & issues; performs additional reviews as necessary (e.g. Special [e.g. ambulance], Billing, Provider, Remain-at-Work [RAW], Voc Rehab [i.e. Job Placement Services])
Serves as agency expert in vocational rehab services & billing: provides insight & expertise into impact of vocational &/or RAW services on employers’ worker’s compensation premiums; educates vocational rehab case managers on provisions of rehab services in accordance with agency policies & guidelines; clarifies & makes recommendations for vocational processes & BWC rehab policies; participates in vocational work groups as necessary & communicates results to management.
Performs other related duties & projects as assigned (e.g. attends training programs, submits weekly, monthly & quarterly compliance reports, attends meetings): reads & monitors local & national vocational trends & patterns which may impact rehab decision-making &/or customer service; reviews rehab programs & recommends improvements to individual plans.
Completion of graduate major core coursework in rehabilitation counseling; 6 mos. exp. in rehabilitation counseling; must be able to provide own transportation.
Major Worker Characteristics:
- Or completion of graduate major core coursework in nursing or comparable field to rehabilitation counseling or nursing which must have included knowledge of at least seven of following areas: (1) history & systems of rehabilitation, (2) planning, implementation & evaluation of services, (3) legislation, ethics & professional conduct, (4) human development & behavior, (5) aspects of disabling conditions, (6) analysis, synthesis & utilization of rehabilitation research & theoretical information, (7) overview of disability compensation systems, (8) structure & process of disability compensation systems, (9) professional terminology, (10) insurance rehabilitation case management, (11) gathering, synthesizing & dissemination of information, (12) forensic rehabilitation; 6 mos. exp. in rehabilitation counseling; must be able to provide own transportation.
- Or valid certification as certified rehabilitation counselor or certified rehabilitation insurance/specialist as issued by Commission On Rehabilitation Counselor Certification, or valid licensure as licensed professional counselor as issued by Ohio Counselor & Social Worker Board, or certificate as certified rehabilitation registered nurse as issued by appropriate body, or valid licensure as registered nurse; 18 mos. exp. in rehabilitation counseling; must be able to provide own transportation.
- Or 6 mos. exp. as Industrial Rehabilitation Case Management Specialist, 69771; must be able to provide own transportation.
- Or equivalent of Minimum Class Qualifications For Employment noted above may be substituted for the experience requirement, but not for the mandated certification or licensure.
Knowledge of: rehab counseling; medical case management or comparable field which includes at least seven of the following areas (a. history & systems of rehab, b. planning implementation & evaluation of services, c. legislation, ethics & professional conduct, d. human development & behavior, e. aspects of disabling conditions, f. analysis, synthesis & utilization of rehab research & theoretical information, g. overview of disability compensation systems, structure & process of disability compensation systems , h. professional terminology, i. insurance rehab case management, j. gathering, synthesizing & dissemination of information, k. forensic rehab); auditing*; medical terminology; public relations; BWC policies & procedures with regards to MCOs*; interviewing techniques. Skill in: operation of personal computer; use of Microsoft Office products (e.g. Outlook, Word, Excel, Access); use of BWC specific software* (V3, PEACH, MIRAII, Cambridge & Data Warehouse). Ability to: review & assess medical & vocational data affecting capabilities of claimants; check, modify & approve all case management reports & forms completed by case managers; deal with a variety of variables in somewhat unfamiliar context, add, subtract, multiply & divide whole numbers, fractions, decimals & percentages; complete routine forms; maintain accurate records; originate routine business letters reflecting standard procedures; understand manuals & verbal instructions, technical in nature; prepare meaningful, concise & accurate reports; handle sensitive inquiries from & contacts with officials & general public; present findings before specialized audiences (e.g. MCOs, BWC management); address multiple issues & work circumstances at MCO site during audits; travel (e.g. involving overnight stays); work in non-office setting.
(*) Developed after employment. Position requires travel; therefore, persons occupying this position must be able to provide own transportation &/or legally operate a state-owned vehicle. UNUSUAL WORKING CONDITIONS: this position requires the ability to travel & work in a non-office setting. Some overnight stays required. Non-standard work schedule required as dictated by operational need.
Unless required by legislation or union contract, candidates can expect to be paid at the lowest rate of the salary range associated with this position.
EDUCATIONAL TRANSCRIPT REQUIREMENT:
Official educational transcripts are required for all post-high school educational accomplishments where the applicant is seeking to meet minimum qualifications and/or position-specific minimum qualifications by way of education. Applicants who are not employed by BWC must submit an official transcript at the time of interview or the applicant will be eliminated from further consideration. Applicants who are BWC employees must have an official transcript on file in the Personnel Office by the deadline date of the job posting. Please note that a transcript is only considered “official” if it is an original copy from the educational institution containing an institutional watermark, ink stamp, or embossed (textured) stamp. Transcripts printed from the institution’s website will not be accepted.
State of Ohio - 2 years ago
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