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Functional Title: Operations SME- Medicaid, CHIP and Health Texas Women
Job Title: Program Specialist IV
Agency: Health & Human Services Comm
Department: HTW ADMIN 1115
Posting Audience: Internal and External
Occupational Category: Business and Financial Operations
Salary Range: $4,263.16 - $6,779.25
Additional Shift: Days (First)
Telework: Not Eligible for Telework
Regular/Temporary: Regular
Full Time/Part Time: Full time
FLSA Exempt/Non-Exempt: Nonexempt
Job Location City: AUSTIN
Job Location Address: 701 W 51ST ST
MOS Codes:
16GX,60C0,611X,612X,63G0,641X,712X,86M0,86P0,88A0,88B0,8U000,OS,OSS,PERS,YN,YNS
Brief Job Description:
Program Specialist IV reports to the Manager of Provider Resolution and Administrative Appeals and performs highly complex (senior-level) consultative services and technical assistance work relating to Medicaid, Children’s Health Insurance Program (CHIP), and Health Texas Women (HTW) programs. The PRAA unit provides oversight of the Texas Medicaid administrative contractors in the areas of claims management, provider enrollment, and administrative appeals. PRAA also handles customer service inquiries for provider enrollment and claims, provider administrative appeals for claim payments, reviews of claims administration and provider enrollment, and oversees contract requirements for provider enrollment, administrative appeals, training, and claims administration.
The PS IV position has extensive latitude for the use of initiative and independent judgment. Tasks include, but are not limited to: conducting complex analysis, research, and development of recommendations in response to Medicaid, CHIP, and HTW escalated provider issues and operations identified by program providers, HHS, stakeholders, and/or the Texas Medicaid & Healthcare Partnership (TMHP); assist in the collection, organization, analysis, and/or preparation of materials in response to requests for program information and reports; preparing and reviewing literature, statutes, rules, and/or policies; preparing justifications for the implementation of procedural or policy changes; and developing policy and procedure manuals; act as the subject matter expert in projects related to provider certifications, enrollment, administrative appeals and other related workgroups/meetings; review program rules, policies, laws, regulations and procedures for contract compliance; work closely with other HHS department staff and TMHP on various assignments and projects related to provider certifications, enrollment, administrative appeals or provider issues.
Essential Job Functions (EJFs):
Attends work on a regular and predictable schedule per agency leave policy and performs other duties as assigned. Researches, analyzes, and evaluates provider issues, program and policy issues, complaints, trends, and initiatives related to Medicaid/CHIP and HTW enrollment, certification, and health care policy; develops implementation and improvement recommendations and other reports related to Medicaid/CHIP and HTW enrollment and certification policies and procedures; and participates in development of policies that facilitate Medicaid/CHIP and HTW operations; and implements policy changes. Coordinates between clients, providers, and contractors to make determinations and resolve problems and issues. The specialist performs highly technical and analytical customer service, public information, and follow-up activities for the Medicaid (traditional and Managed Care) and HTW programs. (30%)
Leads, facilitates, and participates in provider enrollment and certification projects, internal and external workgroups, and provider/stakeholder meetings. Specialist participates in workgroups and public meetings regarding acute care and HTW program and policy issues, initiatives, and Medicaid and HTW program changes, and participates in special investigations, studies, and program analysis projects. Reviews, analyzes, and comments on proposed legislation, public and internal documents, and regulations affecting assigned program and policy areas and audit findings. Prepares project updates, summaries, reports, or other documents and keeps supervisor informed on pertinent issues. (20%)
Provides technical assistance including assessments of compliance, identification of issues and associated solutions regarding providers, contractors, claims processing, IT systems, general operations, etc. (20%)
Completes analysis of contractor performance by synthesizing contractor data, performance reports, quality management reports, technical assistance and training documentation, and other pertinent data as it relates to contractor performance. Communicates the results and recommends actions on a routine basis to program leadership as appropriate. (15%)
Analyzes legislation to develop recommendations for policy and programmatic issues relating to the implementation, improvement, and/or expansion or reduction of program funding. Responds to legislative inquiries and direction. Assist in the implementation of legislatively related direction. (10%)
Other duties as assigned. (5%)
Knowledge, Skills and Abilities (KSAs):
Knowledge of Health and Human Service programs, including Medicaid, CHIP, and HTW. Knowledge of local, state, and federal laws related to Medicaid, CHIP, and HTW programs. Knowledge of Medicaid claims payment models. Knowledge of customer relations principles and practices. Knowledge of and experience in contract performance analyses and monitoring procedures. Knowledge of managed care, health care, health insurance programs, health and human services policies and procedures. Knowledge of the relationships between customer services and medical management areas within a health management corporation. Knowledge of Medicaid SAVERR/TIERS eligibility system, Phoenix, Project, and Portfolio Management, and OnBase reports. Skill in leadership, project management, and time management. Skill in effective oversight to include planning, development, and implementation of systems and processes. Skill in researching, developing, analyzing, and evaluating complex program and policy issues. Skill in managing multiple and competing priorities. Skill in meeting facilitation, problem-solving, and conflict resolution. Skill in working collaboratively and cooperatively with diverse groups. Ability to manage activities, prepare reports, establish goals and objectives, and devise solutions to problems. Ability to communicate professionally and effectively both orally and in writing. Ability to work collaboratively with peers to establish program goals and priorities. Ability to identify and analyze problems, evaluate alternatives, and propose effective solutions. Ability to interpret and explain complex programs policies and procedures, and rules, regulations, and guidelines. Skill in establishing and maintaining effective working relationships and ability to work cooperatively in a team environment. Ability to coordinate with other staff, departments, officials, agencies, organizations, and the public. Ability to lead workgroups, projects, and meetings.
Registrations, Licensure Requirements or Certifications:
N/A
Initial Screening Criteria:
Four years of experience in Medicaid, Healthy Texas Women, Claims Administration, or other health and human services programs preferred. Experience researching, analyzing, developing, and evaluating Medicaid and/or Healthy Texas Women programs. Experience communicating with external stakeholders such as advocacy groups, elected officials, agencies, and the public. Graduation from an accredited four-year college or university. Experience and education may be substituted for one another on a year-for-year basis.
Additional Information:
N/A
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Active Duty, Military, Reservists, Guardsmen, and Veterans:
Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.
ADA Accommodations:
In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.
Pre-Employment Checks and Work Eligibility:
Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.
HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form
Telework Disclaimer:
This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
