Specialty Health Eligibility Specialist

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Brief Job Description:

Responsible for performing eligibility determination functions for the programs administered by Specialty Health (SH), including the Kidney Health Care (KHC) Program, the Children with Special Health Care Needs (CSHCN) Services Program, and the Hemophilia Assistance Program (HAP). May also provide eligiblity support for other SH programs. Responsibilities include determining eligibility, providing technical assistance to internal and external partners for the completion of program eligibility, and maintaining client eligibility status.  Coordinates and verifies client benefits.  Monitors clients to ensure compliance with rules, policies, and procedures.  Makes recommendations for action based on findings.  Responds to inquiries regarding eligibility determination of benefits.  Reports directly to the SH Eligibility Supervisor in the SH Client Services Unit with regard to scope of work and assignments.  

Essential Job Functions (EJFs):

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.  

EJF #1: Determine eligibility for the Specialty Health (SH) programs, including Kidney Health Care (KHC) Program; Children with Special Health Care Needs (CSHCN) Services Program; Hemophilia Assistance Program (HAP); along with eligibility support with other SH programs.  (40%)

EJF #2: Identify, verify, and validate all third-party insurance coverage’s during the application determination process. Correctly coordinate all third-party benefits in accordance with program rules, policies, and procedures. Submit correct coordination plan to the SH Eligibility Team's Insurance staff and verify that they have coordinated the client benefits correctly and accurately.  (25%)

EJF #3: Correctly setup approved clients as a vendor in the State Comptroller’s payee system in accordance with program rules, policies, and procedures. Reconcile voucher errors and respond to fiscal inquiries timely and accurately.  (15%)

EJF #4 : Serve as an eligibility subject matter expert to internal and external customers and other stakeholders. Assist all stakeholders in understanding SH eligibility rules and requirements. Offer concise answers and provides easily understandable examples of eligibility and system processes. Attend meetings and conference calls as assigned to provide expertise and stay knowledgeable of current changes to the program by attending trainings and staying knowledgeable with updates to policy and procedure manuals.  (15%)

EJF #5: Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.  (5%)

Knowledge, Skills and Abilities (KSAs):

Knowledge of community and government service delivery systems; case management delivery systems;  state and federal laws, case guidelines, regulations, and policies; programs which support client populations served by Specialty Health about the evaluation of eligibility; individual needs associated with special health care needs/disabilities and related community welfare resources. 

Skill in interviewing and communicating with clients, case managers, and social workers for the purpose of conducting individual needs assessments; providing technical assistance to providers, clients, and professional staff; Skill in navigating interagency procedures; providing customer service support to clients and providers regarding complex eligibility requirements and benefits. 

Ability to convey instructions and explanations to clients and interested parties;  negotiate available services for our client population; develop and interpret policies and procedures, and to assess compliance; communicate effectively with coworkers, clients, and providers; work effectively as a team member. 

Registrations, Licensure Requirements or Certifications:

N/A

Initial Screening Criteria:

Experience in human services work or with public benefit program work, required.

Graduation from an accredited four-year college or university with major coursework in human services, social science, business, or a related field is generally preferred. Experience and education may be substituted for one another on a year by year basis, required.

Experience in providing customer service to clients and providers regarding complex eligibility requirements and program benefits, required.

Experience in eligibility determination, preferred. 

Additional Information:

This position is eligible for telework consistent with HHSC telework policy, which is subject to change. Employees may be required to work in the office one or more days a week.

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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