Operations and Readiness Review Specialist

Brief Job Description:

The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Operational and Readiness Review Specialist. MCS is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by ensuring Managed Care Organization’s (MCOs) meet contract, state, and federal regulations through Operational and Readiness reviews. This position requires the necessity to travel monthly for operational reviews and as well as at a moment's notice based on significant MCO non-compliance. Position will perform highly complex consultative services and technical assistance work. Work involves leading operational and readiness initiatives such as readiness reviews, operational reviews and targeted reviews. Work involves planning, developing, and implementing major agency program(s) and providing consultative services and technical assistance to program staff, governmental agencies, community organizations, or the general public. 

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.

The Operational and Readiness Review Specialist reports to the Manager of the Operational and Readiness Review Team in the Managed Care Contracts and Oversight (MCCO) MCS Division. Work also includes research and developing tools for reviews. Position will work in partnership with HHS program staff and contracted MCOs. Work includes evaluating MCO adherence to contracts, policies, programs, other government assistance and programs and private sector resources. Position will contribute to the development of the monitoring teams within MCCO. Position will apprise manager of work-related incidents or situations that could be problematic to staff, the department or the agency. Position will communicate with manager on a timely basis with regard to problematic situations and apply proper judgment to assure action is appropriate. Position works under limited supervision and with considerable latitude for the use of initiative and independent judgment.

Essential Job Functions (EJF):

1. Ensure compliance with contract standards and assess MCO performance by reviewing MCO contract deliverables, performance measures and MCO compliance with state and federal regulations. 
a. On a prompt and regular basis determine the effectiveness of MCO operational and contractual compliance by utilizing a standard set of assessment tools.
b. Promptly inform the Senior Manager and team lead of significant MCO compliance and performance issues and provide recommendations for action.
c. Facilitate collaboration with other MCCO staff, the MCO, and other external/internal stakeholders to ensure contractual compliance by developing, monitoring, and updating action plans.
d. Work promptly and collaboratively to assess and review recommended remedies for noncompliance of contractual requirements.
e. Collaborate with MCCO Research and Resolution promptly and timely on escalated MCO related issues.
f. Respond to and review legislative, open records and audit requests within specified timeframes.

2. Lead and facilitate functions related to operational on-sites, desk reviews, implementations, readiness reviews, information sessions, or other activities as required.
a. Manage or facilitate special research/issues projects as assigned within timeframes.
b. Develops materials and prepares reports based on findings from readiness reviews.

3. Establishes and maintains effective working relationships and communications with HHS staff, and other internal/external stakeholders, and provide timely responses to requests and inquiries.
a. Receive no more than 1-2 justified complaints per annual review period from internal or external customers regarding professional conduct, appropriate interactions with others, and/or timely responses to requests or inquiries.

4. Demonstrates commitment to the goals of the Medicaid/CHIP services, shows initiative to take on new projects, is team-oriented and committed to outstanding customer service, and focuses on promoting efficiencies and accountability.

5. Communicates with manager in a timely manner regarding problematic situations and applies proper judgment to ensure action taken is appropriate.

6. Attends work on a regular predictable schedule in accordance with agency leave policy. Performs other duties as assigned, timely and accurately.

7. Participates in the development of RFPs and the evaluation of RFP responses within assigned timeframes. Reviews, analyzes and evaluates rules, bills and federal/state laws with implications for the Medicaid and CHIP programs as required.  

Registration, Licensure Requirements or Certifications:

Certified Texas Contract Manager Certification (CTCM), or must obtain within 12 months upon hire. Must maintain CTCM certification.  

Knowledge, Skills and Abilities (KSAs):

1. Knowledge of subsidized health insurance, including Medicaid, Medicaid Managed Care, and/or CHIP. 
2. Knowledge of contract management and compliance principles.
3. Ability to work under limited direction and to use initiative and independent judgment.
4. Analytical and organizational skills and the ability to conduct investigations or audits; gather, assemble, correlate, and analyze facts and data; and devise solutions to problems.
5. Knowledge of state and federal laws, regulations and processes regarding Medicaid Managed Care and CHIP.
6. Skill in using personal computer application software such as Microsoft Word, Excel, Power Point, or other similar programs.
7. Skill in written and oral communication, including the ability to make public presentations, write technical information in an understandable format, produce sophisticated research and analytical reports.
8. Ability to research and evaluate policies and procedures.  

Initial Screening Criteria:

A minimum of 120 semester hours from an accredited college with major course work in a field related to health and human services. Graduation from an accredited four-year college or university with major course work in a field relevant to healthcare administration, health information technolgy, or management is generally preferred. Experience and education may be substituted on a year for year basis. Minimum of two years of experience with Medicaid and CHIP managed care programs, policies, procedures, contracts, and service delivery models. Minimum of two years of experience of contract management and contract principles. Minimum of two years in/with research, analysis and creating technical reports in an understandable format. Minimum of two years of experience in using a PC and Microsoft Office Suite including: Word, Excel, PowerPoint, Outlook.  

Additional Information:

N/A