Claims Examiner III

TX-HHSC-DSHS-DFPS•Bryan, TX

1d•$3,793 - $5,921•Hybrid

About The Position

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. The Access and Eligibility Services (AES) division is looking for individuals who want to join an exciting, dynamic team working in a high-performing and innovative environment. AES provides an integrated and streamlined approach to connect individuals to services and supports that: reduce institutionalization, allow individuals to remain in their communities, and promote economic and personal self-sufficiency. AES is built upon its’ core values of respect, ownership, collaboration, and integrity with a goal of delivering best-in-class customer service to clients and stakeholders. Our staff are well organized, able to multi-task, possess the ability to learn policy regulations, able to thrive in a challenging, fast-paced, and evolving environment, have good communication skills, a positive attitude, strong work-ethic and a desire to help others. This position is responsible for implementation of the disability determination policies/procedures. This position is responsible for reviewing medical and social history information to determine applicant’s ability to perform substantial gainful activity under the Disability Determination application and review process for cases. This position consults with staff physician, regional staff, medical providers, and legislators. This position interprets program policies and procedures, prepares appeal summaries and participates in Fair Hearings for appeal cases. This position works closely with the Disability Determination Manager to develop and maintain uniformity of disability determination processes and decisions. Assists Manager in conducting presentations and training of disability determination policy and procedures to agency staff and others as requested. Assists Manager in coordination of disability determination policy/procedure changes with appropriate policy staff. Provides technical supervision to clerical support staff. This position may require up to 40% of travel.

Requirements

High School diploma or GED equivalent is required.
Sixty (60) semester hours from an accredited college or university is required. Two (2) years of customer service experience may be substituted for required education.
Experience working in a professional customer service environment.
Two (2) years’ experience as an Eligibility Advisor – MES (Medicaid Eligibility Specialist).
Experience (within the last two (2) years) in Medicaid or Medicaid for the Elderly and People with Disabilities (MEPD) policy and procedures.
Experience using computer software such as Microsoft Word, Excel, and Outlook.
Application indicates the willingness to work beyond normal work hours of 8:00 AM – 5:00 PM.
Application indicates the willingness to travel.

Nice To Haves

One (1) year experience as an Eligibility Advisor III – MES (Medicaid Eligibility Specialist) or higher, preferred.
Texas Integrated Eligibility Redesign System (TIERS) and Eligibility Workload Management System (EWMS) experience is preferred.
Experience in medical reporting and terminology, preferred.
Experience analyzing complex state and federal law and regulations, preferred.
Experience analyzing operations and problems and preparing reports of findings and recommendations is preferred.

Responsibilities

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.
Provides interpretation and application of federal disability requirements and procedures in the disability determination process for Medicaid applicants.
Receives social and medical records from the Medicaid Eligibility Specialist and may have direct contact with Medicaid applicants occasionally. The position interprets the medical and social records and applies the "Federal SSI Listings of Impairments" using the five step "Sequential Evaluation Process", to determine if the applicants meet federal requirements for disability eligibility. Errors of interpretations could result in loss of benefits or harm to the applicant’s health. Errors also could possibly result in federal sanctions and loss of Medicaid funds.
Assists in the development of policies, procedures, rules, regulations or standards on disability determination cases.
Provides complex technical assistance to regional staff, medical providers, legislators, and general public on policies, procedures, rules, regulations, standards or requirements in disability cases for Medicaid eligible applicants.
Assists in the development and presentation of training on disability determination policy and procedures.
Testifies as a technical authority and represents Disability Determination by participation in Appeal Hearings.
May conduct program analyses and research to assess and formulate changes in processes or procedures.