Duty Statement



|duty statement |

|Class Title |Position Number |

|Staff Services Manager III |805-200-4802-005 |

|COI Classification | |

|Yes |No |

|Unit |

|Section |

|Branch |

|Clinical Program Integrity Branch Chief |

|Division |

|Clinical Assurance Division, Assistant Division Chief |

|This position requires the incumbent to maintain consistent and regular attendance; communicate effectively, both orally and in writing as appropriate, in dealing |

|with the public and/or other employees; develop and maintain knowledge and skill related to specific tasks, methodologies, materials, tools, and equipment; complete |

|assignments in a timely and efficient manner; and, adhere to departmental policies and procedures regarding attendance, leave, and conduct. |

|Job Summary: This Staff Services Manager III (SSM III) position serves a dual role within the Clinical Assurance Division (CAD), as the Assistant Division Chief |

|(Assistant DC) and as the Clinical Program Integrity Branch (CPIB) Chief. In the role of Assistant DC, the SSM III is responsible for assisting the Division Chief in |

|carrying out CAD’s mission to provide quality clinical oversight that results in appropriate and cost effective care for Medi-Cal members. This includes assisting to |

|manage the entire Treatment Authorization Request (TAR) process, including TAR submission and adjudication, and developing the specific policies necessary for |

|consistent adjudication, statewide, as well as post-payment reviews. |

| |

|As the CPIB Chief, the SSM III will direct efforts to ensure that services provided to fee-for-service Medi-Cal members are medically necessary. The CPIB Chief |

|provides guidance and leadership related to program oversight and integrity to management and clinical staff within multiple Divisions across DHCS. |

|Supervision Received: General direction is provided by the CAD Chief, a Career Executive Assignment, Level B. |

|Supervision Exercised: Manages a Branch of multi-disciplinary staff of approximately 30 state staff positions, largely comprised of licensed professional clinical |

|staff. In the absence of the Division Chief, is responsible for managing all Branches within the Division. |

|Description of Duties: See below. |

| |

| |

|Percent of Time Essential Functions |

| |

|30% Serve as the Assistant Division Chief (Assistant DC), to assist the CAD Chief, with the development, implementation, and evaluation of methods utilized to manage |

|and control costs for medical and benefits based on utilization, including policies that address the processing of TARs to ensure consistent application in all field |

|offices. Including but not limited to: development of a systematic data collection, analysis, and monitoring method to identify discrepancies and inconsistencies in |

|TAR adjudication and implements training and other corrective strategies. Establish priorities and procedures for the compliance review and monitoring processes that |

|are designed to provide a thorough assessment of TARs and assists in developing policies that fully coordinate with other State departments; ensure identification and |

|appropriate implementation of state and federal policies which maximize effectiveness and the prudent expenditure of funds. |

| |

| |

| |

|30% Direct CAD’s CPIB to ensure that services provided to Medi-Cal members are medically necessary. Oversee analyses of patient |

|medical records, Designated Public Hospital TAR-free processes, hospital Diagnostic Related Group (DRG) coding practices, and provider claims to verify that |

|fee-for-service payments to providers match patients’ diagnoses and treatment. Consult and coordinate with other DHCS Divisions such as Safety Net Financing Division |

|and Audits and Investigations to provide program oversight, ensure program integrity, reduce inflated provider claims, and help decrease fraud. Supervises and directs|

|staff in the development, implementation, analysis and evaluation of medical utilization management and clinical assurance policies and procedures. Recommend |

|development, analysis and implementation of utilization standards, payment mechanisms, rules, regulations, and quality controls for covered medical services. |

| |

|15% Coordinate the activities and administrative needs of CAD with other departmental division chiefs; participate in the annual budgeting process, oversee the |

|development of budget change concepts and proposals, including presentations to various groups and the budget committees; provide general direction to branch managers;|

|review personnel needs; and evaluate managerial and supervisory staff performance. As needed, may represent the CAD Chief in meetings with DHCS executive staff, |

|high-level federal and state officials, committees, advocacy groups, and high-level officials of other state departments to build consensus and to discuss and |

|formulate State policies and implementation strategies; participate in sensitive negotiations to resolve differences in program interpretation and application of said |

|information. |

| |

|10% Consult, establish, and maintain liaison and cooperative relationships with the medical professionals, including statewide professional and provider |

|organizations, allied health groups, and other public/private agencies engaged in health and medical services. May represent DHCS before peer groups, other provider |

|groups, and community organizations to advise them on the medical aspects of the Medi-Cal program. May require occasional travel. |

| |

| Percent of Time Marginal Functions |

| |

|5% Recruitment, hiring, training, and evaluation of subordinate staff. Perform other related duties that are within the scope of this classification as required. |

| |

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|Employee’s signature |Date |

|Supervisor’s signature |Date |

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