CSHCN Eligibility Specialist

TX-HHSC-DSHS-DFPS • Tyler, TX

16d

About The Position

Under the supervision of the Regional Manager of Specialized Health/Social Services or designee, participates as a member of the comprehensive social work program (Children with Special Health Care Needs Services Program (CSHCN-SP),
Newborn Screening (NBS), Newborn Hearing Screening (NBHS), Childhood Lead Poisoning Prevention Program (CLPPP), Personal Care Services and Private Duty Nursing (PCS/PDN), and Children’s Health Insurance Program (CHIP). Works under moderate supervision with limited latitude for use of initiative and independent judgment, performs complex public health and human services work, and renders decisions on Children with Special Health Care Needs (CSHCN) Program eligibility for clients in HSR 4/5N. Provides complex reviews of CSHCN applications, including reviews of financial and medical information to determine applicability of CSHCN Program rules. Interprets and complies with CSHCN rules, regulations, policies and procedures relating to CSHCN eligibility. Follows established procedures for CSHCN automated "IBIS" system eligibility processing. Develops, coordinates and maintains up to date records of all applications and outcome determinations processed and collects data, keeping breakdown totals on those received, approved, denied, sent to Austin for appeal and ones processed under specific spenddown procedures. Also maintains program statistics. Assures daily determination information letters are generated and audited, including information for Medicaid/Medically Needy Program and Children's Health Insurance Program (CHIP), which are necessary for the completion of the CSHCN application process. Serves as a public resource and confers on a daily basis with other regional eligibility personnel, social workers, medical staff, and personnel from other agencies to provide technical assistance, policy, interpretation/updates, problem resolution, and follow up on incomplete applications. Maintains computer database, files, documentation, reports and performs routine clerical duties for assigned social work staff. Works as part of a team with other eligibility staff. Employee actively participates and/or serves in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Maintains confidentiality. Attends to other assignments as directed by Regional Manager of Specialized Health/Social Services or designee. Provides translation services (English and Spanish) as needed.

Requirements

• Knowledge of social, economic, and public health issues.
• Knowledge of working with computer systems and software applications.
• Knowledge of medical terminology and medical care specialties.
• Knowledge of DSHS and HHSC client services programs and Medicaid covered services.
• Skill in use of computer programs and maintaining information systems.
• Skill in organization, prioritizing, planning , problem-solving, attending to details, and meeting deadlines.
• Skill in implementation of program policies and procedures.
• Skill in coordinating and scheduling.
• Skill to function in a culturally competent manner.
• Ability to maintain confidentiality.
• Ability to select and evaluate relevant facts from case records and application forms in relation to eligibility criteria.
• Ability to understand and interpret policies and make decisions related to eligibility determinations.
• Ability to work independently; ability to work well with others as a team member.
• Ability to communicate effectively, both verbally and in writing, in English and Spanish, and explain program services to clients, providers, professionals, and public.
• Ability to read, write, and speak English and Spanish at a conversational level.
• Ability to travel locally and out-of-town for training and/or meetings.
• Must possess a valid Texas Driver's License.
• Ability to read, write, and speak in both English and Spanish, with bilingual abilities to be tested at interview.
• Graduation from an accredited four-year college or university with major course work in human services or a related field.

Responsibilities

• Performs complex reviews of applications for determination of program eligibility including evaluating applications and supplemental information for eligibility bases on financial, residency, age and medical criteria; performs complex data entry; interviews applicants and collateral sources as necessary to follow-up incomplete applications. Provides translation services (Spanish and English) as needed.
• Provides technical assistance to regional social work staff, CSHCN providers and/or potential providers concerning provider enrollment, authorization and claims processing. Assists case managers in the resolution of problems between clients, providers of services, and regional staff. Works directly with providers to obtain authorizations for services and filing claims as needed. Provides interpretation of relevant changes as they occur. May interview and provide guidance and assistance to clients with completion and submission of eligibility applications for Medicaid/Medically Need Program and CHIP, assuring compliance with timelines mandated by the CSHCN Program. Answers or returns all telephone inquiries regarding eligibility status by providing prompt and correct information on CSHCN rules and individual cases. Provides translation services (Spanish and English) as needed.
• Works with local health agencies, private physicians, individuals, and community action groups to enhance awareness of prevention of chronic diseases and childhood disabilities. Provides information to potential clients about agency programs and services and distributes published materials outlining eligibility requirements. Serves as an information and referral source to the public regarding appropriate community resources.
• Assists with gathering data and performs research utilizing agency-approved methods. Assists in preparing client charts for long-term storage. Assists with coordinating long-term storage retrievals/transportation with Central Office. Creates, translates, edits, and maintains usable forms for Specialized Health and Social Services in Spanish.
• 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. Attends work on a regular and predictable schedule in accordance with agency leave policy. Other duties as assigned by the Manager of Specialized Health/Social Services or designee.

Benefits

• DSHS offers insurance coverage and other benefits available through the State of Texas Group Benefits Plan administered by the Employee Retirement System of Texas (ERS).

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level