HEALTH SYSTEM SPECIALIST-SERVICE UNIT

GS-671-09

I. [Introduction:]{.underline}

This position is organizationally located in the Contract Health
Services (CHS) Branch, Service Unit, Indian Health Service. The purpose
of this position is to provide support and technical assistance to the
Service Unit management on matters involving CHS including medical,
surgical, dental, hospital and clinical services to all eligible
beneficiaries in conjunction with or in lieu of IHS facilities.

II\. [Major Duties:]{.underline}

Serves as the specialist responsible for evaluating and reporting on CHS
services provided by the Service Unit. Investigates and analyzes
controversial issues and develops drafts related to reports,
correspondence and other written material. Assists in developing
policies and procedures in the CHS Program.

Performs liaison functions with contract health providers, state and
local agencies; and monitors/reports status of CHS activities and funds.
Prepares analytical data, staff reports and memoranda which reflect
utilization of CHS resources.

Issues purchase orders obligating CHS funds, then electronically submits
purchase order information to the contracted fiscal intermediary for
IHS. Determines those cases that patients may qualify for alternate
resources and/or catastrophic health emergency funds.

Performs high cost case management of expenditures for determining those
cases with catastrophic illnesses in order to request and receive
reimbursement of Catastrophic Health Emergency Funds.

Participates in Quality Assurance/Utilization Review by conducting CHS
Review Committee meetings.

Responsible for evaluating pertinent contract health cases and
assembling, analyzing and checking statistical data. Advises patients
and their families concerning eligibility and other facets of the CHS
Program. Plans and develops orientation materials for patients,
families, and hospital staff concerning CHS.

The incumbent considers the personal and medical factors that differ
with each patient, such as economic status, educational level, medical
problems, treatment methods, and progress of the patient. The specialist
identifies the various factors to be considered and advises the
physician on specific CHS requirements.

Offers CHS assistance to eligible Indian people within fund limitations
and operates within medical priorities. Conducts on-site patient
interviews to establish eligibility for IHS patients for CHS. Provides
assistance to individuals applying for services from other sources
including medicare, V.A., CMS and AFDC.

Initiates Medical Purchase orders to include periods of hospitalization
and medical fees for professional services. Responsible for the
maintenance of complete Document Control Registers indicating Government
appropriated funds for Contract patient care. Informs the Chief,
Financial Management and Service Unit Director of the current status of
funds available on a regular basis. Recommends adjustments in medical
priorities when limited funds warrant.

Reviews completed claims submitted by vendors, and EOBRS received from
the FI. Returns unclear or incomplete documents to health providers.
Compares services provided against contract terms, and enters data to
ensure that system operations are accurate. Contacts CHS providers and
explains IHS policies and contract care procedures. Establishes and
maintains a cooperative working relationship with contract vendor staff.

Issues correspondence to patients, health care providers and other
agencies regarding eligibility, IHS policy and regulations, including
letters of denial of claims. Insures confidentiality of patient
information. Maintains denial, deferred and appeals tracking for
reporting.

Audits claims processed for patient eligibility for third party
programs, proper codes which indicate primary provider code, diagnosis,
and clinic code.

Directs the maintenance of the commitment registers, a daily log of
obligations processed. Reviews automated data for comparison with manual
data and when errors are detected locates the source and executes
appropriate corrective action. Resolves nonstandard processing problems
which subordinate staff cannot resolve. Key enters and verifies all
fiscal and statistical data through use of ADP equipment.

Prepares correspondence to third-party providers to obtain data on
services provided. Represents CHS in Service Unit meetings.

Performs [supervisory functions]{.underline} including work planning and
scheduling and directing as well as all Personnel Administration and
management functions. [Provides supervisory]{.underline}
[responsibilities over 1-3 staff members]{.underline}.

Performs other related duties as assigned.

III\. [Factors]{.underline}

l\. [Knowledge required by the position.]{.underline}

Knowledge of Health Care Delivery Systems.

Knowledge of Contract Medical Care policies and procedures.

Knowledge of Fiscal Intermediary claims processing procedures both
electronically and manually.

Knowledge of Catastrophic Health Emergency Funds.

Knowledge of Third party billing systems.

Knowledge of IHS automated data processing system. Knowledge of
supervisory methods and procedures.

Knowledge ICD-CM and CPT-4 coding.

Knowledge of specialized Medical Terminology.

Knowledge of basic accounting methods.

Knowledge of basic acquisitions and contracting methods.

2\. [Supervisory Controls]{.underline}

Work is assigned by the Supervisor who provides the incumbent with
instruction of what is to be accomplished. The incumbent executes
routine work assignments independently but consults the supervisor on
situations which are very complex, controversial or precedent setting.
Work is reviewed by conformance to policy and procedure and
accomplishment of work elements in the employee\'s annual performance
plan.

3\. [Guidelines]{.underline}

IHS Circulars/Manuals, State, Federal, and Public Laws, IHS Procedural
Manual,

ICD-9-CM Code Manual, and JCAHO Accreditation Manual. Incumbent must use
individual judgement the interpretation and application of these guides.

4\. [Complexity]{.underline}

The work involves processing a wide variety of transactions and
compiling reports for Contract Health applications and third party
billing activity. Work requires identifying transaction types,
extracting, compiling and verifying payment data, computing and
adjusting account balances, preparing required forms and records, and
submitting and maintaining current assignment of benefits.

5\. [Scope and Effect]{.underline}

Purpose of the work is to assure maximum utilization of Contract Health
funds by a comprehensive CHS eligibility determination and use of all
available alternate resources and contractor contracts/agreements. This
work generates approximately percent of all Service Unit income and
expenditures.

6\. [Personal Contacts]{.underline}

A wide variety of contacts are made. This includes patients and
families, direct medical providers, contract providers and vendors,
insurance carriers, tribal and community agencies and various other
Federal, State and Local agencies.

7\. [Purpose of Contacts]{.underline}

Contacts are made with patients and families and providers to obtain
medical data and information and to explain IHS Contract Health Care
policies and procedures and to determine Contract Care eligibility.
Contacts with Contract vendors is to negotiate cost equities and
fulfillment of contract provisions. Contact with third party carriers is
for the purpose of exchanging information and resolution of payment
disputes.

8\. [Physical Demands]{.underline}

The work is located in a health care facility with some walking and
movement through the hospital and prolonged sitting.

9\. [Work Environment]{.underline}

Work is generally performed in an office setting.

EVALUATION STATEMENT

[Position]{.underline}: Health System Specialist, GS-671-09

[Organizational Location]{.underline}: Contract Health Services, IHS
Service Unit.

[Reference]{.underline}: OPM PCS for Health System Specialist, GS-671
series 12/79;

OPM PS for Management and Program Analysis, GS-343 Series 8/90;

HHS Guide for Contract Health Positions 1/94.

[Title/Series Determination]{.underline}:

Subject position assignments require a knowledge of the basic practices
and principles related to Health Care Delivery System Management. This
type responsibility is characteristic of work included in the series
definition of the cited GS-671 series which is allocated.

[Grade Level Determination]{.underline}:

Subject position is classified by direct application of Administrative
Analysis Grade Evaluation Guide as depicted on the FES position
evaluation statement. Supervisors may request the FES evaluation from
Headquarters-CHS.

[Conclusion]{.underline}: Health System Specialist, GS-671-09.

/s/

Vernon E. Hohmann

Position Classification Specialist April 5, 1994