Specialty Health Program Specialist IV

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Brief Job Description:

Under the direction of the Contract and Reimbursement Manager, the Specialty Health Program Specialist performs advanced (senior-level) reimbursements and program services. Work involves processing prompt and efficient payments of medical claims, travel claims, audits adjustments and insurance premiums for contracted providers and clients enrolled within Specialty Health programs. Researches reconciliation discrepancies and reports findings. Conducts trainings, leadsplanning, developing, and implementing recommendations for program areas needing changes and improvements.  Works closely with following programs: Kidney Health Care, Hemophilia Assistance Program, Epilepsy Program, Navigate Life Texas and may assist with customer service support for specialized programs within Specialty Health. Reviews inquiries received from clients, providers and the general public regarding eligibility status, claims status, benefits, and limitations. The Program Specialist ensures compliance with program and accounting policies, guidelines, procedures, statutes, and rules; and takes corrective actions as needed. Works under minimal supervision, with extensive latitude for the use of initiative and independent judgment.

Essential Job Functions (EJFs):

(EJF 1) Analyzes and processes medical claims, travel claims, payment tracers, and Medicare Part D insurance premiums requests submitted by enrolled providers and clients for payment. Reviews and performs claims adjustments of previously paid claims. Completes and monitors administrative and performance reports, specialized projects, billing, and collection activities for Specialty Health programs. Ensures that all data necessary to support the review and analysis of performance metrics are available for regular review by stakeholders and clients. Uses standard office equipment, a computer and applicable computer systems and software such as automated claims billing system, client eligibility and enrollment systems, and Microsoft Office suites of programs. (30%)

(EJF 2) Assists in developing program policies, procedures, and standards related to claims and reimbursements in accordance with Specialty Health program objectives and goals. Provides support and input of all programs as necessary or dictated by the needs of the office. Conducts training and provides guidance to staff in the development and integration of new or revised methods and procedures related to claims and reimbursement.  The role requires regular collaboration and communication with internal program subject matter experts, contract managers, and external stakeholders such as contracted providers, social workers, and enrolled clients. 20%

(EJF 3) Performs review and analysis of program operations and problems and prepares reports of findings and recommendations. Gathers financial data to be used in reports to management. Conducts reviews to monitor compliance with state and federal laws, rules, and regulations pertaining to reimbursements that are highly complex in nature or large in scale. Assists with developing, prioritizing, tracking, and monitoring program-wide projects and initiatives related to claims and benefit utilization for Specialty Health program improvement and development. 20%

(EJF 4) Acts as primary point of contact with contracted and enrolled providers regarding claims, billing, and reimbursement for assigned Specialty Health programs. Consults with program providers to resolve problems, identify training needs, and discuss program effectiveness.  Oversees resolutions of billing problems and financial determinations. Communicates with program areas and makes recommendations to address existing or potential problem areas. Facilitates and participates in work groups to develop and implement solutions in an effective and professional manner. Participates and collaborates in the evaluation and implementation of Specialty Health practices for quality assurance, quality improvement, efficiency, and effectiveness to resolve issues or improve performance.  Works within the scope of work as determined by the Reimbursement Manager. 15%

(EFJ 5) Assists Specialty Health Managers and leadership with senior-level initiatives to support other Specialty Health business areas. Provides alternatives and solutions leveraging strategic messaging, communication principles and industry best practices. 10%

(EJF 6) Other duties as assigned. Duties may include actively participating, serving in a supporting role, or assisting in work to maintain continuity of operations of the agency during a disaster response and recovery effort. 5%

Knowledge, Skills and Abilities (KSAs):

Knowledge

Knowledge of local, state, and federal laws related to the program area; public administration and management techniques; budget processes; research techniques; training techniques; and program management processes and techniques; principles of collection and accounting, and the rules and regulations governing reimbursement for agency services; standard claim processing forms such as the CMS-1500 and UB04; medical terminology and coding systems, including International Classifications of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT) codes.

Skills

Skill in identifying measures or indicators of program performance and the use of a computer and applicable software; resolving problems; in reviewing and evaluating options; in implementing solutions; in interviewing techniques; and in the use of standard office equipment, a computer, and applicable computer software; using automated claim payment systems; interpreting rules, policies and procedures.

Ability

Ability to gather, assemble, correlate, and analyze facts; to devise solutions to problems; to market programs; to prepare reports; to develop, evaluate, and interpret policies and procedures; to communicate effectively; and to serve as a lead worker providing direction to others; use independent judgment and initiative to complete detailed and multiple assignments under pressure of deadlines; to identify problems, plan and carry out corrective action; to communicate effectively, and to supervise the work of others.

Registrations, Licensure Requirements or Certifications:

N/A

Initial Screening Criteria:

High School diploma or equivalent.

Minimum of 3 years experience in reimbursements of medical claims and invoice processing in a healthcare or human services organization.

Experience in interpreting accounting rules, policies, guidelines and procedures.

Preferred Criteria

Experience in managing financial documentation such as HCFA 1500 claims forms, expenditures, and invoices.

Experience in resolving billing discrepancies, communication with insurance and stakeholder.

Experience in using computer software applications such as Outlook, Excel, and Power Point for trainings and financial reports to management.

Additional Information:

N/A

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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.