Program Specialist VI

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Brief Job Description

The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) Office of Policy seeks a highly qualified candidate to fill the position of Program Specialist VI. 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 performing highly advanced consultative, technical, and analytical work related to the research, development, and implementation of Medicaid medical benefits policy. This position will work on high priority and critical medical policy projects and must be proactive in seeking input from other staff in the Medicaid/CHIP Division and demonstrate the ability to work as an effective team member with other divisions within HHSC, and other HHS agencies. This position must be able to research, analyze, and synthesize information such as current standards of care, evidence-based practices, and peer reviewed literature and apply findings to medical benefit policies in review.

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 Program Specialist VI reports to one of the Medical Benefits Policy Managers. This position works under limited direction of the Manager with extensive latitude for the use of initiative and independent judgment.

Essential Job Functions

(25%) Serves as the Lead in the development, planning, and implementation of complex new or current medical benefit policies. Researches, analyzes, and synthesizes medical policy documents, complicated federal regulations, client information, and complex provider enrollment management (PEMS) and claims processing systems information for each benefit review. Identifies and provides the applicable Code of Federal Regulations (CFR), State Plan, and Texas Administrative Code (TAC) citations for policy reviews by performing technical research using online resources and electronic databases. Attends medical policy workgroup meetings and provides recommendations on medical policy information verbally or in writing.

(25%) Researches, analyzes, and synthesizes very technical information such as standards of care, evidence-based practices, and peer reviewed literature using a variety of resources and websites and applies findings to medical benefit policies. Conducts complex research on MCO benefit coverage, private payer benefit coverage, and other state Medicaid benefit coverage during the policy development process. Assists in the development and review of complicated medical policies including reviewing documentation, policy language development, tracking document research, and reviewing discussions and draft benefit policy changes. Performs complex quality review of policy language, PEMS and claims processing system changes to ensure all changes are appropriate and have been captured accurately. Documents and escalates issues to the Medical Benefits Policy Manager.

(25%) Develops complex memos, briefs and other documents for HHSC Executive Leadership regarding medical policy changes. Develops and provides recommendations for benefit coverage to HHSC Executive Leadership. Develops, submits and coordinates policy changes to Rules and the Medicaid State Plan. Collaborates with HHSC staff and other HHS agencies to oversee and provide comments on medical policies, Texas Medicaid Provider Procedures Manual, and other materials to ensure that the information is accurate and in accordance with policies and procedures. Works with external stakeholders, HHS agencies and vendors to resolve policy issues, discuss program effectiveness, and identify training needs.

(15%) Leads and/or participates in special medical and policy projects, such as dual client eligibility for Medicare and Medicaid, and provides guidance to staff in the development and integration of new benefits by reviewing documents and analyzing provider questions or concerns. Prepares technical project summaries and keeps Executive Leadership updated on projects in a timely manner. Ensures compliance with medical policies, rules and statues. Leads or participates in public meetings or workgroups engaged in research, analysis, and evaluation of policy issues or initiatives.

(10%) Performs and prepares medical policy and program materials in response to internal/external requests in a professional and timely manner. Serves as a resource for new employees and internal/external staff by providing training, direction, and guidance on the development of medical policies. Gives presentations to groups and facilitates and participates in policy meetings for internal staff, intra-agency partners, vendors, stakeholders, the general public, or Legislative staff.  Reviews complaints concerning current medical policies by providers and other reviewers. Works with internal and external entities to identify the need for policy changes through the analysis of claims appeals and denials, provider complaints, and prior authorization requests. Responds in timely manner to internal/external communications and requests for current medical and dental benefit policy information. Works collaboratively across MCS to identify innovative and effective solutions for clients and staff. Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Registrations, Licensure Requirements or Certifications:

N/A

Knowledge, Skills, and Abilities

Knowledge of:

• Health and human services agencies and programs, and state and federal Medicaid and CHIP laws and regulations,
• Policy development, and
• The use of Microsoft Office products.

Skill with:

• Analyzing and evaluating complex federal and state legislation;
• Researching, analyzing, and synthesizing medical policy, claims processing, PEMS system, and program issues;
• Developing and evaluating policies and procedures, assessing risks, and making recommendations;
• Written and oral communication, including the ability to make public presentations, and write technical information in an understandable format; and
• Project planning, evaluation, and implementation.
  
  

Ability to:

• Maintain a high level of organization and manage several projects concurrently in a busy work-environment with shifting and competing priorities;
• Operate with a keen attention to detail and the ability to implement creative solutions to problems;
• Ability to effectively facilitate meetings and maintain working relationships with staff or program stakeholders;
• Work collaboratively across MCS to accomplish objectives;
• Work cooperatively as a team member in a fast-paced, deadline-orientated environment;
• Work independently and perform work with a high degree of attention to detail; and
• Balance team and individual responsibilities.

Initial Selection Criteria 

Required:

Graduation from an accredited four-year college or university.

Preferred: 

A minimum of two years’ experience with policy analysis, health care policy and/or Medicaid/CHIP policy.

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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.