Quality Assurance & Appeals Manager

Class Concept

This class includes positions that manage the Recipient Hearings & Appeals Section in DHHS or the DHHS Hearings Office. The Recipient Hearings and Appeals Section processes appeal requests arising from applicant/recipients having a right to appeal a County Department of Social Services decision that grants, denies, terminates, or modifies assistance; or the failure of the County to act in a reasonable time. The DHHS Hearings and Appeals Section conducts impartial informal appeals by Medicaid and Health Choice providers regarding adverse determinations, holds hearings for long-term care residents who are being transferred or discharged from an adult care home or nursing facility, holds hearings for individuals who appeal a preadmission screening and resident review; and conducts second level reviews for Health Choice recipients who have a denial, reduction, suspension or termination of health services. Positions are responsible for planning work operations; determining staffing levels; assigning hearings considering workload and location; reviewing cases for timeliness, thoroughness, and reasonableness of decisions and compliance with all Federal and State requirements; reviewing overall organizational accomplishments and planning for improvements; recruiting, orienting and training new employees; reviewing employee performance; and working with employees to improve performance. Positions are responsible for representing the department with other State and Federal agencies and/or coordinating work with them.

Recruitment Requirements

Knowledge, Skills, and Abilities

• Thorough knowledge of the regulations, rules and laws governing hearing subjects.
• Considerable knowledge of quasi-judicial procedures; administrative law principles and procedures.
• Working knowledge of medical terminology.
• Ability to interpret and apply complex department policies, administrative rules, general statutes, and both Federal and State regulations to include Privacy and HIPAA laws and ability to manage a comprehensive and diverse docket..
• Ability to listen to and evaluate testimony using reasoning and logic to conceptualize legal judgments and ability to engage in legal research.
• Ability to communicate clearly, concisely, effectively, and professionally, both orally and in writing and ability to understand and translate complex medical and regulatory.
• Ability to work independently and be highly organized to include excellent time management skills
• Ability to relate to a variety of individuals in the medical profession, legal profession, staff at county Departments of Social Services, and appellants.
• Excellent analytical skills for program development and evaluation and ability to problem solve and manage complex situations for effective resolution.
• Ability to establish and maintain effective working relationships with appeal staff, department and division staff, attorneys and public and ability to assign work and supervise staff to develop, plan, and implement appeals procedures and policies.

Minimum Education and Experience

Bachelor's degree from an appropriately accredited institution and five (5) years of experience as a hearings officer, claims adjudicator, or manager of a business or government program; or an equivalent combination of education and experience.