Job description
The Program Specialist II reports to the Medical Director in the Medicaid and CHIP Office of the Medical Director (OMD). This position works primarily with the HHSC Medical & Utilization Review Appeals unit, reviewing and managing appeals and communicating with stakeholders regarding technical issues. The Program Specialist reviews, interprets, and investigates questions or concerns expressed by clients, providers, patient advocacy groups and other interested parties.
Work involves in-depth analysis of inquiries, open records requests, and other issues; interpretation of Texas Medicaid/CHIP rules, regulations, policies, and procedures; conducting research to resolve issues and problems; and composing
written responses.
Work requires handling confidential documentation in accordance with agency security policies.
Work entails using initiative and independent judgment, under limited supervision, to prepare, monitor, and complete all scheduled tasks in an accurate, sensitive, and timely manner.
The ideal candidate thrives in an environment that emphasizes teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.
Work involves in-depth analysis of inquiries, open records requests, and other issues; interpretation of Texas Medicaid/CHIP rules, regulations, policies, and procedures; conducting research to resolve issues and problems; and composing
written responses.
Work requires handling confidential documentation in accordance with agency security policies.
Work entails using initiative and independent judgment, under limited supervision, to prepare, monitor, and complete all scheduled tasks in an accurate, sensitive, and timely manner.
The ideal candidate thrives in an environment that emphasizes teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.
Essential Job Functions:
(65%) Manages Medical and Utilization Review (UR) Appeal Cases, which includes receiving appeal documentation, ensuring completeness and timely receipt, categorizing cases, entering cases in databases, preparing and sorting case files, and preparing and faxing request and acknowledgment letters. Analyzes provider submissions to determine whether they have been received timely and meet technical requirements for valid appeal submission. Tracks appeal cases in databases (HEART or contractor portal). Updates the appropriate database entering receipt of new appeal cases, additional documentation requests and receipt, and closure and archiving of appeal cases. Manages the flow through the appeal system and records essential updated information in appropriate databases and tools. Requests and manages documentation from other HHS agencies and contractors. Communicates with other HHS agencies and contractors regarding appeal case information. Maintains documentation of appeal determinations.
Monitors ongoing statistics on the appeal process and prepares reports.
(5%) Completes UR Final Technical Denial cases within required timeframe by reviewing documentation submitted by provider and ensuring HHSC OIG Utilization Review followed correct procedures when requesting hospital medical records.
(15%) Coordinates communication between Medicaid/CHIP Division and the Office of the Medical Director and its Medical and UR Appeals team, advocate groups, stakeholders and other internal/external groups or associations. The position involves accurate, clear, and professional verbal and written communication with other departments and external stakeholders. Reviews, researches, and investigates complex complaints, problems, and questions received from clients, providers, other government agencies, and other interested parties and provides appropriate and concise oral and written responses within specified deadlines. Assumes responsibility for information provided to and received from these various groups. Compiles information, organizes and summarizes communication for management. The specialist evaluates email, mail, and telephone queries from appealing providers and other stakeholders regarding appeal status and program rules and replies in a timely, sensitive, and accurate manner. Ensures issues and inquiries requiring immediate action are appropriately addressed and refers more detailed responses to appropriate staff for resolution.
(10%) Prepares and designs correspondence, reports and presentations.
Prepares reports for weekly team meetings and monthly reports for HHSC Medicaid/CHIP Medical Director based on ongoing statistics regarding appeal processes and provider communications.
Prepares reports for other HHS agencies, as needed. Develops, coordinates, and maintains electronic and paper files; and retrieves information as requested by staff. Ensures that documents are clear, relevant, concise and grammatically correct. Gathers research and analyzes request data, policies, procedures, contract requirements, and operational issues and compiles written determinations. Responds both verbally and in writing to inquiries, complaints, and internal and external requests from providers, contractors, program staff, government agencies, and professional associations. Provides management with organized summaries of team communication with internal and external parties and identifies trends or issues in stakeholder communication.
(5%) Conducts special projects or other duties as assigned in support of the Medicaid and CHIP Services Division.
(65%) Manages Medical and Utilization Review (UR) Appeal Cases, which includes receiving appeal documentation, ensuring completeness and timely receipt, categorizing cases, entering cases in databases, preparing and sorting case files, and preparing and faxing request and acknowledgment letters. Analyzes provider submissions to determine whether they have been received timely and meet technical requirements for valid appeal submission. Tracks appeal cases in databases (HEART or contractor portal). Updates the appropriate database entering receipt of new appeal cases, additional documentation requests and receipt, and closure and archiving of appeal cases. Manages the flow through the appeal system and records essential updated information in appropriate databases and tools. Requests and manages documentation from other HHS agencies and contractors. Communicates with other HHS agencies and contractors regarding appeal case information. Maintains documentation of appeal determinations.
Monitors ongoing statistics on the appeal process and prepares reports.
(5%) Completes UR Final Technical Denial cases within required timeframe by reviewing documentation submitted by provider and ensuring HHSC OIG Utilization Review followed correct procedures when requesting hospital medical records.
(15%) Coordinates communication between Medicaid/CHIP Division and the Office of the Medical Director and its Medical and UR Appeals team, advocate groups, stakeholders and other internal/external groups or associations. The position involves accurate, clear, and professional verbal and written communication with other departments and external stakeholders. Reviews, researches, and investigates complex complaints, problems, and questions received from clients, providers, other government agencies, and other interested parties and provides appropriate and concise oral and written responses within specified deadlines. Assumes responsibility for information provided to and received from these various groups. Compiles information, organizes and summarizes communication for management. The specialist evaluates email, mail, and telephone queries from appealing providers and other stakeholders regarding appeal status and program rules and replies in a timely, sensitive, and accurate manner. Ensures issues and inquiries requiring immediate action are appropriately addressed and refers more detailed responses to appropriate staff for resolution.
(10%) Prepares and designs correspondence, reports and presentations.
Prepares reports for weekly team meetings and monthly reports for HHSC Medicaid/CHIP Medical Director based on ongoing statistics regarding appeal processes and provider communications.
Prepares reports for other HHS agencies, as needed. Develops, coordinates, and maintains electronic and paper files; and retrieves information as requested by staff. Ensures that documents are clear, relevant, concise and grammatically correct. Gathers research and analyzes request data, policies, procedures, contract requirements, and operational issues and compiles written determinations. Responds both verbally and in writing to inquiries, complaints, and internal and external requests from providers, contractors, program staff, government agencies, and professional associations. Provides management with organized summaries of team communication with internal and external parties and identifies trends or issues in stakeholder communication.
(5%) Conducts special projects or other duties as assigned in support of the Medicaid and CHIP Services Division.
Knowledge Skills Abilities:
Knowledge of office practices and administrative procedures.
Knowledge of customer relations principles and practices.
Knowledge of Texas HHS and Medicaid policies and procedures, functions, state and federal laws and regulations, and operations of Medicaid/CHlP programs.
Knowledge of medical and utilization review and appeal processes.
Knowledge of Medicaid eligibility and claims systems.
Skill in effectively organizing, tracking, and developing written and electronic documents.
Skill in processing and handling Medicaid medical appeals.
Skill in communicating effectively, both verbally and in writing.
Skill in dealing with internal and external customer relations.
Skill in the use of computers and programs such as Microsoft Outlook, Word, PowerPoint and Excel.
Skill in the use of computer systems (examples include, but are not limited to, HEART, TMHP Phoenix system, MCATS, and the TexLinx archive management system).
Ability to interpret and explain complex program policies and procedures, rules and regulations.
Ability to set-up and maintain complex filing systems.
Ability to learn new computer programs and systems.
Ability to prioritize and complete multiple tasks within tight deadlines.
Ability to work independently within the context of role expectations and responsibilities.
Ability to deal effectively and courteously with staff and the public through telephone, email, and personal contact.
Ability to establish and maintain effective working relationships and to work cooperatively in a team environment.
Ability to build positive relationships with physician, nursing and administrative staff, and stakeholders.
Knowledge of office practices and administrative procedures.
Knowledge of customer relations principles and practices.
Knowledge of Texas HHS and Medicaid policies and procedures, functions, state and federal laws and regulations, and operations of Medicaid/CHlP programs.
Knowledge of medical and utilization review and appeal processes.
Knowledge of Medicaid eligibility and claims systems.
Skill in effectively organizing, tracking, and developing written and electronic documents.
Skill in processing and handling Medicaid medical appeals.
Skill in communicating effectively, both verbally and in writing.
Skill in dealing with internal and external customer relations.
Skill in the use of computers and programs such as Microsoft Outlook, Word, PowerPoint and Excel.
Skill in the use of computer systems (examples include, but are not limited to, HEART, TMHP Phoenix system, MCATS, and the TexLinx archive management system).
Ability to interpret and explain complex program policies and procedures, rules and regulations.
Ability to set-up and maintain complex filing systems.
Ability to learn new computer programs and systems.
Ability to prioritize and complete multiple tasks within tight deadlines.
Ability to work independently within the context of role expectations and responsibilities.
Ability to deal effectively and courteously with staff and the public through telephone, email, and personal contact.
Ability to establish and maintain effective working relationships and to work cooperatively in a team environment.
Ability to build positive relationships with physician, nursing and administrative staff, and stakeholders.
Registration or Licensure Requirements:
N/A
N/A
Initial Selection Criteria:
Graduation from an accredited four-year college or university and a minimum of two years’ of work experience with Medicaid or CHIP programs. An equivalent combination of related educational and work experience may be used to the substitute for the graduation requirement.
Graduation from an accredited four-year college or university and a minimum of two years’ of work experience with Medicaid or CHIP programs. An equivalent combination of related educational and work experience may be used to the substitute for the graduation requirement.
Additional Information:
MOS Code:
This position does not have anything to do with MOS.
This position does not have anything to do with MOS.
Top 10 Tips for Success when Applying to Jobs at HHSC and DSHS
HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.
In compliance with the Americans with Disabilities Act (ADA), HHS 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.
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