Ombudsman II

Job Description:

Ombudsman II Under the direction of the Managing Ombudsman of the Managed Care Assistance Team in the HHS Office of Ombudsman, the Ombudsman II performs intake, provides information and referral, and researches and resolves moderate to complex issues, for clients enrolled in Medicaid and Medicaid managed care programs. Work involves intake of contacts related to HHS program and services related to Medicaid; providing information and assistance to Health and Human Services consumers; and ensuring access to needed health services. Assistance includes: explaining the Medicaid managed care system, helping clients understand their rights and responsibilities, investigating complex issues and complaints, coordinating with Managed Care Organizations (MCOs), state agencies, and providers to help consumers successfully navigate the Medicaid managed care system. Responsible for: receiving moderate to complex issues and complaints from HHS clients, providers, advocacy groups, and other stakeholders; entering issues in a database; resolving complex issues; maintaining a caseload, notifying supervisor of unresolved cases; referring non-Medicaid related complaints and issues to appropriate area or agency; coordinating with other areas to mediate and achieve resolution, tracking ongoing cases to ensure resolution timelines are met; and identifying recurring issues and notifying management with recommendations for improvement. Work under general supervision with limited latitude for the use of initiative and independent judgment.  

Essential Job Functions:
Essential Job Functions:
EJF 1. On a daily basis, follow unit procedures to provide courteous and professional service on all contacts received by HHS clients, providers, advocacy groups, HHS program areas, and other stakeholders. Resolve moderate to complex issues and complaints by: • Performing in-depth analysis of moderate to complex issues and complaints which includes: researching and interpreting state and federal rules and regulations, agency procedures, and client rights and responsibilities via Uniform Managed Care Manual, Medicaid Managed Care (MMC) contracts, HHS MMC handbooks, state and federal statutes and Texas Administrative Code; interpreting client specific information in HHS and vendor eligibility and enrollment systems, and researching the internet; and determining whether a complaint may be handled within the initial contact or requires investigation. • Conducting investigations by interviewing complainants, HHS program areas, providers, vendors, and MCOs, and making requests for information and/or documentation from HHS program areas, clients, providers, MCOs, other HHS vendors, and from any other party involved in the investigation. • Facilitating the sharing of information among entities involved in a complaint. Mediate among HHS clients, providers, HHS program areas, MCOs, advocacy organizations, HHS vendors, and/or local resources to generate options for resolution of issues and complaints. • Analyzing results of investigations. Making determinations regarding program and policy compliance, preparing findings, and ensuring resolution of issue/complaint. • Providing accurate and appropriate information and referrals to HHS clients regarding other HHS program areas and vendors, other state agencies, and local resources. • Educating and advising stakeholders on Medicaid and MMC policies, procedures, state and federal rules and regulations, the Fair Hearing and appeal process, and empowering HHS clients to navigate the HHS system and advocate for themselves when possible. (30%) EJF 2. On a daily basis, conduct intake of issues and complaints received by HHS clients, providers, advocacy groups, other HHS program areas, and other stakeholders. Handle escalated issues from Ombudsman I staff. Take calls on a statewide toll-free helpline, respond to emails, online submissions, faxes and letters. Maintain production by handling share of incoming contacts within established guidelines and requirements and adhering to scheduled work activities. (35%) EJF 3. On a daily basis, accurately and thoroughly document all issues, actions, analysis, findings, and resolution in the Ombudsman database. Correspond via email, fax, or letter with HHS clients, HHS program areas, HHS vendors, providers, MCOs, and advocacy organizations. Write detailed investigation reports for the Ombudsman Director when requested by management. (20%) EJF4. On open investigations, follow up regularly with the client and other parties involved in the issue/complaint. On open assignments, track to ensure timely and complete responses, prompt involved entities when necessary and report late responses on referred issues to management within specified timeframes. (10%) EJ5. Report to Ombudsman management recurring issues and problem trends that may affect the administration of HHS programs management, with recommendations for improvement to include HHS policy/procedure changes, changes to TAC, or vendor contract changes. (5%)  

Knowledge Skills Abilities:
a) Knowledge of applicable state and federal laws, regulations, and policies relevant to Medicaid and Medicaid Managed Care benefits and Health and Human Services programs, services and procedures. b) Ability to interpret, analyze, and evaluate complex program policy and rules and regulations and make accurate assessments. c) Ability to determine complexity of issue and triage to appropriate agency or program. d) Skill in the use of computers and related equipment and software, including Windows, Word, Excel, Outlook, and database software. e) Skill in communicating effectively, both verbally and in writing. f) Ability to meet tight deadlines. g) Skill in establishing and maintaining effective working relationships with clients and coworkers, including the ability to work with people under pressure. h) Ability to work on an Automated Call Distribution (ACD) hotline. i) Skill in using eligibility and claims databases. j) Skill in conducting research using internet and other sources, investigating complaints, recognizing problems and facilitating solutions, in complaint resolution. k) Ability to use an automated tracking system. l) Ability to work and communicate with individuals in personal crises and in confrontative situations as evidenced by the ability to maintain control of a call. m) Ability to elicit factual information or perform required duties in order to proceed with an investigation. n) Skill in mediation and conflict resolution. o) Ability to interact with all clients, internal and external, using empathy and compassion. p) Ability to coordinate with other staff, departments, organizations, and the public.  q) Ability to conduct thorough investigation, make impartial decisions based evidence and reasoning.

Registration or Licensure Requirements:
 N/A

Initial Screening Criteria:
Experience within in the past year working with Texas Medicaid benefits and services. Experience with researching, resolving, and responding to HHS complaints. Past or present experience as an Ombudsman is generally preferred. Graduation from an accredited four-year college university with major course work in social work, psychology, sociology, or related field is generally preferred.  

Additional Information:
Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual.

Employees are responsible for providing the necessary infrastructure for teleworking, including office furnishings (desk, chair, lamps, etc.), and utilities (reliable internet, electricity, telephone). The agency will not reimburse for utilities, or any items purchased for telework use, including office supplies, internet service, or maintenance or repair of personally owned equipment. Travel to a regional HHS office for pick up or repair HHS-issued equipment may be required.

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Only current HHS employees may apply. An In-basket will be provided during the interview.

The offered salary will be determined in accordance with budgetary limits and the requirements of the HHS Human Resources Manual.

Note: Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include: 73A and 425X. For more information see the Texas State Auditor’s Military Crosswalk at http://www.hr.sao.state.tx.us/Compensation/JobDescriptions.aspx. req 333246 HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work. I-9 Form - Click here to download the I-9 form. 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.  

MOS Code:
73A and 425X
HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.
I-9 Form - Click here to download the I-9 form.
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.
 

HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

I-9 Form - Click here to download the I-9 form.

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.

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.