|HEALTH SYSTEM SPECIALIST-AREA
This position is organizationally located in the Contract Health Services (CHS) Division, Area Office, Indian Health Service. The function of the division is to manage the Area provision of health care through outside contracting. The purpose of this position is to serve as a Health System Specialist providing support to management by analyzing, developing, implementing, evaluating, coordinating and consultation on program activities related to Contract Health Services. Incumbent represents the program and performs difficult and responsible assignments that are Area-wide in scope and require expertise and judgement to support broad contract health service and third party alternate resource objectives.
II. Major Duties:
Participates in the management of the Area Contract Health division and provides consultant services to Area management and field staff. Implements and interprets Area and Headquarters CHS policies and procedures. Ensures the compliance with these policies in areas of eligibility determination, fund control and accountability and acquisition of third-party resources.
Conducts analysis of policies and directives pertinent to CHS administration and management to define requirements and objectives. Provides general consultation and technical guidance in the establishment of new or redefined CHS operating program guides, policies and procedures. Makes recommendations concerning the modification, extension or termination of program supported objectives and activities. Develops and documents reports, manuals, staff papers and correspondence on applicable subjects and issues.
Participates in the establishment and implementation of a comprehensive medical priority system that will most effectively serve quality health care delivery within available resources.
Conducts or participates in reviews and evaluations of Area CHS operations to determine progress, conformity to program requirements and identifies deficiencies and problems affecting cost and delivery of services. Recommends corrective action and methods to resolve problems and achieve compliance with policy.
Responds to inquiries and requests for CHS assistance via telephone, written communication or personal visit. Coordinates these requests and provides consultation to resolve problems or issues. These requests in many instances originate from a variety of sources requiring contact with outside agencies and organizations.
Ensures implementation and administration of comprehensive CHS denial and appeal procedures. Implements decisions made in second level process of denial of services and prepares correspondence for Area Director signature. Assures that controls are established and that responses are prepared in a timely manner and in conformity to established policies and regulations.
Reviews denial letters to ascertain the appropriateness of decisions in keeping with Federal appeal regulations and IHS policies.
Informs and advises service units and tribal programs when denials appear unjustified which may result in further appeal to the Area Director or Headquarters.
Recommends and participates in the establishment of policy concerning the acquisition of third party resources and assures that appropriate mechanisms are in place to accomplish this objective.
Provides training and technical support to the field in administrative skills necessary to manage CHS activities such as automated systems and preparation of medical authorizations.
Responsible for data collection and analysis for special reports and assures that reports are prepared in a timely manner and that they contain all required information. Provides guidance and instruction to originators on information requirements, modifications in processing methods and proper reporting procedures.
Monitors the catastrophic health emergency fund for the Area Office. Receives all requests for reimbursement, reviews to insure appropriate documentation is included and that guidelines have been followed and forwards the package to IHS Headquarters.
Works with appropriate professional and medical staff to assure continuous development and implementation of an appropriate methodology for evaluation of the amount and quality of the health care services purchased under contractual agreements.
Performs other related duties as assigned.
1. Knowledge required by the position
Knowledge of the concepts, principles, practices, methods, and techniques IHS program administration, CHS and Third-party resources.
Knowledge of IHS and Area priorities, policies, goals and objectives
Knowledge of Health Care Delivery Systems.
Knowledge of Business Office Program operations.
Knowledge of Federal and State laws that pertain to health care delivery and contracts.
Ability to analyze problems and make written and oral presentations.
Ability to participate in reviews, assessments and evaluations.
2. Supervisory controls
The supervisor provides general direction by outlining specific goals an objectives to be achieved. The incumbent independently plans, organizes and executes work assignments. More difficult and controversial situations may be discussed with the supervisor prior to action taken. Work is reviewed in terms of overall accomplishments and by conformity to established broad policies and procedures.
Guides consists of Federal regulations, Headquarters and Area directives and instructions. In most cases these guides are broad in nature requiring the incumbent to make interpretive decisions and judgements in adapting them to specific situations.
Cultural, political and government regulatory considerations combine to complicate many aspects of program delivery. This, coupled with the need to reconcile IHS/CHS priorities and goals with those of outside organizations with whom the incumbent deals, combine to further increase the complexity of the position by requiring an almost continuous need to modify policies and procedures to accomplish the work assignments.
5. Scope and effect:
Assignments are area-wide in scope and require expertise and judgement to support broad CHS and third party resource goals and objectives. Assignments characteristically require the development and application of new program methods and approaches. The incumbent's actions, conclusions, recommendations and decisions often determine policy, affect the utilization of substantial resources and have considerable impact on the Area Health Delivery System.
6. Personal contacts:
As a principal area consultant the incumbent comes into contact with a myriad of diverse groups, each with their own agenda. Contacts are with IHS Headquarters staff, senior Area managers, Professional health providers, tribal groups, other Federal State and local agencies, hospitals, third party carriers and other outside organizations.
7. Purpose of contacts:
Meetings with various groups and individual contacts are for the most part designed to discuss, negotiate and reconcile differences with contract health care providers and beneficiaries, third party resource organizations, tribal groups and others involved in the Contract Health Services Program. Other purpose of contacts include providing advice, training and disseminating policy and procedural information.
8. Physical demands:
The position requires little physical demands other than sitting and walking.
9. Work environment:
Work is performed in an office setting.
Position: HEALTH SYSTEMS SPECIALIST, GS-671-12
Organizational Location: Contract Health Services Branch, IHS Area Office
Standards Referenced: Health System Specialist, GS-671 Series; Management and Program Analysis Series GS-343; DHHS Classification Guide for Contract Health Positions.
Subject position is a mix of program analysis, management, claims analysis, adjudication and technical support assignments. The preponderant purpose of the position involves staff work within a Health Management organization which warrants title and series allocation of Health System Specialist, GS-671-12.
Grade Level Determination:
The cited GS-671 standards do not contain published grading criteria which prevents direct application for grade level determination. The GS-671 standard directs the reader to the Management and Program Analysis GS-343 for cross reference grading purposes. This standard provides two factors for this purpose.
Complexity of assignment:
Comparison is made with the GS-11/12/13 grade level criteria in the cited standard. At the
GS-11 level, analysts establish standard organizational patterns and standard procedures for several organizations with similar functions. Recommendations are always cleared with the supervisor and studies are primarily local in impact. The GS-12 level criteria depicts assignments of broader scope and breadth than those performed at the GS -11 level. The functions studied at this level are considerably more varied. At the GS -13 level functions are extremely complex and cover organizational structure of several levels and have national impact.
Subject position's complexity level exceeds the GS -11 criteria in that the assignments cover multiple functions, i.e. claims adjudication, technical support, planning etc., but does not meet the GS-13 criteria because assignments do not fully impact organizational structure of several levels. Subject position's complexity level is a substantial match for GS-12 level criteria for this element.
Level of responsibility:
Subject position receives broad general assignments which are executed with considerable independence. Recommendations for work changes are not necessarily cleared with the supervisor before execution except on extremely complex, controversial or precedent setting cases.
Recommendations are usually accepted and work is reviewed in terms of overall accomplishment of objectives. This is commensurate with GS-12 level described in the cited standard. Grade Level Allocation is GS-12.
Health System Specialist, GS-671-12
Vernon E. Hohmann Personnel Classification Specialist, IHS April 8, 1994