Research Specialist II

Job Description:

The Texas Health and Human Services Commission (HHSC) Office of Inspector General (OIG)’s mission is to improve the health, safety, and well-being of Texans through good stewardship of public resources and a focus on core public health functions. OIG is a dynamic organization that specializes in the prevention, detection, and investigation of fraud, waste, and abuse in the provision of all state health and human services, enforcing applicable state and federal regulations. The OIG’s Third Party Recoveries (TPR) division is responsible for promoting federal and state requirements related to ensuring that Medicaid is the payor of last resort. The TPR team’s work consists largely of overseeing the contractors who administer Medicaid claims and perform data matching activities to both prevent and recover overpayments when another (third) party was liable for paying for a client’s service instead of Medicaid.

Under the supervision of the OIG’s Third Party Recoveries (TPR) manager, this position will provide contract management support and research support to OIG TPR. Work involves data gathering and compilation, as well as assistance overseeing a broad range of TPR contracts including Fee-For-Service, Managed Care Organizations and Texas Medicaid & Healthcare Partnership. Work involves research, evaluation, and consultative service work. Assists the TPR Manager with collaborating with other HHSC divisions that oversee contracts that include TPR scope. The position is responsible for coordinating with internal OIG staff, HHS staff, other state and federal agencies, contractors, and external stakeholders to strengthen Medicaid Third Party Liability (TPL) program policy and promote compliance with federal and state TPL rules and regulations.

This position coordinates duties and activities with the TPR Manager and Director, performs moderately advanced research, evaluation, consultative, and technical work requiring specialized knowledge in planning, developing, implementing, interpreting, and ensuring compliance with TPL program policy and federal and state rules and regulations. Work involves assisting with development and implementation of quality assurance and contract monitoring activities, as well as monitoring, responding to, and tracking other insurance (OI) emails from MCOs and DMOs as well as other internal and external stakeholders. The position coordinates critical data requirements, data analysis, reporting protocols and follow-up related to TPR activities. Additionally, the position is responsible for identifying opportunities to develop and implement TPL program policy changes to decrease Medicaid fraud, waste, and abuse; improve compliance with federal and state TPL rules and regulations; and/or reduce inefficiencies related to TPL activities performed by Medicaid vendors and the MCOs/DMOs. This position is also responsible for adhering to procurement and contracting policies, rules, and statutes. Participates in other programmatic activities as assigned. This position performs moderately complex (journey-level) research work under general supervision with moderate latitude for the use of initiative and independent judgement. 

Essential Job Functions:

Serves as a research specialist subject matter expert for TPR program policies in both fee-for-service and managed care. Assists with TPR-related reports and findings for compliance. Analyzes reports for trends and TPR program compliance. Assists with the preparation of reports for overall contract management, internal and external information requests, and distribution of responses/feedback concerning performance measures and contract deliverables. (40%)

Monitors, responds to, researches, and tracks other insurance (OI) emails from MCOs and DMOs as well as other internal and external stakeholders. (30%)

Consults and communicates, individually or collectively, with contractors, state staff, community stakeholders, and state and local authorities to identify needs, resolve problems, discuss effectiveness of programs and services, and implement program improvements. (15%)

Develops policies and procedures to ensure accountability and documentation related to program performance measures and contract management. Recommends policy changes and business process enhancements to increase the efficiency and effectiveness of the TPR program. (10%)

Performs other duties, as assigned. Keeps manager informed as required or necessary. (5%)  

Registrations, Licensure Requirements or Certifications:

None  

Knowledge Skills Abilities:

• Knowledge of state and federal laws and regulations relevant to Medicaid and other public health care programs.
• Knowledge of data analysis and research concepts and techniques and their application to performance measurement.
• Knowledge of research methods, principles, techniques, and philosophies.
• Knowledge of systems and procedures used to test and evaluate project performance.
• Ability to plan, organize, manage, and coordinate research projects.
• Ability to evaluate research data.
• Ability to ensure development of measuring instruments with respect to reliability, relevance, and validity.
• Ability to interpret, publish, and present research findings.
• Ability to communicate effectively, both orally and in writing.
• Ability to coordinate activities among public, private, and professional groups, express ideas clearly and concisely, address audiences effectively, and exercise sound judgment in evaluating situations and making decisions.
• Skill in conducting qualitative and quantitative research.
• Skill in the use of data analysis tools and methodologies.
• Skill in the use of Microsoft Office Suite products, including Outlook, Word, Excel, PowerPoint, and Teams.
• Skill in researching, developing, and writing professional reports and/or presentation materials.
• Skill in problem solving and independent decision making.
• Skill in leading staff work processes, setting priorities, and monitoring progress.
• Skill in developing and evaluating policies and procedures; assessing risks and developing contingency plans; and making recommendations for improvement.
• Skill in synthesizing complex and technical information and translating it into understandable and concise documents and presentations.
• Skill in interpersonal relationships, including the ability to work with people under pressure, negotiate among multiple parties, resolve conflicts, and establish and maintain strong and effective working relationships.
• Skill in managing multiple and competing priorities.
  
  
  

Initial Screening Criteria:

Additional Information:

 Telework Disclaimer:

A minimum of two years’ experience working with Medicaid, other health and human services programs, or health care – preferably involving compliance with government regulations.
Experience with Health & Human Services (HHS) programs is strongly preferred.
Experience working with the Texas Integrated Eligibility Redesign System (TIERS) is preferred.
Experience working with stakeholders and diverse groups preferred. 

This is currently a hybrid position (in-office and 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.