Waiver Eligibility Team Operations Specialist (PS II)

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Brief Job Description

The Waiver Eligibility Team Operations Specialist (Program Specialist II) reports to the Waiver Eligibility Medical Director in the Medicaid and CHIP Services (MCS) Office of the Medical Director (OMD). This position supports the waiver eligibility team through planning, organizing, and coordinating key business functions such as state fair hearings. The Operations Specialist reviews and investigates questions or concerns expressed by clients, Medicaid managed care organizations (MCOs), providers, and other interested parties. 

MCS is driven by its mission to deliver quality, cost-effective services to Texans. OMD provides clinical consultation and guidance to other areas within MCS, throughout the agency, and to external stakeholder organizations. It works to provide a clinical vision for improving the health of Texans by aligning MCS programs with state public health priorities. In addition to the waiver eligibility team, OMD leads the utilization review team of MCS which is charged with ensuring that individuals receive medically necessary, cost-effective services.

Work requires:

• Providing support to the waiver eligibility team and leading collaboration in the operational aspects of conducting medical necessity determinations for Medicaid waiver programs, including but not necessairly limited to Medically Dependent Children Program (MDCP);
• In-depth analysis of inquiries, complaints, and other programmatic issues; interpretation of Texas Medicaid/CHIP rules, regulations, policies, and procedures;
• Conducting research to resolve issues and problems; composing written responses; and creating external-facing informational presentations;
• Handling confidential documentation in accordance with agency security policies;
• Using initiative and independent judgment, with limited latitude, under general supervision, to prepare, monitor, and complete all scheduled tasks in an accurate, sensitive, and timely manner; and
• In-office collaboration.

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.

Essential Job Functions:

(45%) Coordinates medical necessity reviews for Medicaid waiver programs to include MDCP. Reviews, collates, and ensures timely receipt documentation to support medical necessity. Coordinates state fair hearings through supporting calendaring, staffing, and communicating with the fair/fraud hearings area of the agency.

(20%) Categorizes cases, enters cases in databases, prepares and sorts case files, and prepares and sends fair hearing packets and other correspondence. Updates the appropriate database entering receipt of new appeal cases, additional documentation requests and receipt, and coverage of fair hearings. Requests and manages documentation from other HHS agencies and contractors. Communicates with contractors and clients regarding medical necessity case information. Monitors ongoing statistics on the medical necessity determination process and prepares reports.
 

(15%) Coordinates communication between Medicaid/CHIP Division and the Office of the Medical Director’s waiver eligibility team with advocate groups, stakeholders and other internal/external groups or associations. Reviews, researches, and investigates complex complaints, problems, and questions received from clients, providers, other government agencies, and other interested parties and provides appropriate responses within specified deadlines. Assumes responsibility for information provided to and received from these various groups. Compiles information, organizes and summarizes communication for management. Ensures issues and inquiries requiring immediate action are appropriately addressed and refers more detailed responses to appropriate staff for resolution. Identifies trends or issues in stakeholder communication.
 

(10%) Prepares reports for weekly team meetings and monthly reports for HHSC Medicaid/CHIP Medical Director based on ongoing statistics regarding medical necessity processes and provider communications. Prepares and designs correspondence, reports and presentations. Develops, coordinates, and maintains electronic and paper files; and retrieves information as requested by staff. Ensures that documents are clear, relevant, concise and grammatically correct. Gathers research and analyzes request data, policies, procedures, contract requirements, and operational issues and compiles written determinations.
 

(10%) Conducts special projects or other duties as assigned in support of the Medicaid and CHIP Services Division.

Registrations, Licensure Requirements, or Certifications:

N/A

Knowledge, Skills, Abilities:

Knowledge of:

• Office practices and administrative procedures;

• Customer relations principles and practices; and

• Texas HHS and Medicaid policies and procedures, functions, and operations of Medicaid/CHlP programs.

Skill in:

• Effectively organizing, tracking, and developing written and electronic documents;

• Processing and handling administrative and clinical documentation;

• Communicating effectively, both verbally and in writing;

• Dealing with internal and external customer relations;

• The use of computers and programs such as Microsoft Teams, Outlook, Word, PowerPoint, SharePoint, and Excel;

• The use of web-based applications (examples may include online health information portals and program eligibility systems).

Ability to:

• Interpret and explain complex program policies and procedures, rules and regulations;

• Set-up and maintain complex filing systems;

• Learn new computer programs and systems;

• Prioritize and complete multiple tasks within tight deadlines;

• Work using initiative and independent judgment, with limited latitude, under general supervision within the context of role expectations and responsibilities;

• Deal effectively and courteously with staff and the public through telephone, email, and personal contact;

• Establish and maintain effective working relationships and to work cooperatively in a team environment; and

• Build positive relationships with physicians, nursing and administrative staff, and stakeholders.

Initial Screening Criteria:

• A minimum of two years  experience providing complex administrative and/or operational support for a key business program or process;

• An undergraduate degree from an accredited college or university (education and experience may be substituted for each other on a year for year basis); and

• Ability to prioritize and complete multiple tasks within tight deadlines.

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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.