PASRR Specialized Services Policy Reviewer
About The Position
The Program Specialist V position reports to the Pre-Admission Screening and Resident Review (PASRR) Manager within the Intellectual and Developmental Disability (IDD) Services and PASRR Section. This position performs highly complex senior-level work and is responsible for assisting the manager and the PASRR Specialized Services Lead with reviewing, adjudicating, and authorizing requests for specialized services under the PASRR program. The position evaluates supporting documentation, applies applicable PASRR policies and rules, and determines whether requests meet requirements for authorization. This position also provides technical assistance and policy clarification to stakeholders and providers on procedures, policies, and rules related to PASRR, with an emphasis on specialized services authorization and related claims or payment issues. The position identifies, communicates, and supports resolution of documentation or system issues that may affect service authorizations, claims or payments. Works under limited supervision, with moderate latitude for the use of initiative and independent judgment. Ideal candidates should be comfortable with change, skilled at navigating ambiguity, and capable of quickly pivoting when systems or processes prove ineffective or inefficient. If you're energized by meaningful work, ready to build sustainable systems that improve lives, and excited to make a difference in the IDD community, we encourage you to apply.
Requirements
- Knowledge of PASRR processes, policies, regulations, and specialized services authorization requirements.
- Knowledge of reimbursement claims processing concepts, and factors that may affect claims payment for authorized services.
- Strong organizational and time management skills to handle workload and deadlines.
- Analytical and problem-solving skills to review service requests, evaluate supporting documentation, and identify authorization or claim-related issues.
- Attention to detail and accuracy.
- Excellent communication skills to provide technical assistance and clarification to various stakeholders.
- Skills in using Microsoft Office products.
- Ability to work independently and collaboratively in a fast-paced environment.
- Ability to communicate effectively both verbally and in writing
- Ability to gather, assemble, and analyze business requirements.
- Ability to develop and or maintain complex spreadsheets using Microsoft Excel.
- Graduation from an accredited four-year college or university with major course work in a human services field is required. One year of relevant experience may be substituted for each year of required education.
Nice To Haves
- At least 2 years of experience in the IDD services field is preferred
- Experience reviewing documentation, analyzing authorization or claims issues, and supporting resolution of complex payment concerns is preferred.
- Experience working at a LIDDA or IDD provider is preferred.
Responsibilities
- Review, adjudicate, and authorize requests for nursing facility specialized services and IDD habilitative specialized services for PASRR-eligible people living in nursing facilities. Ensure requests are reviewed accurately and within required timeframes using automated and manual processes and verify that supporting documentation meets PASRR specialized services authorization requirements. (50%)
- Provide technical assistance and policy clarification to external providers on PASRR procedures, policies, and rules, including requests for nursing facility specialized services submitted through the TMHP Long Term Care (LTC) Online Portal and IDD habilitative specialized services processed through manual procedures. Assist providers and stakeholders in understanding documentation requirements, authorization outcomes, and issues that may affect PASRR specialized services authorization, claims processing or payment. (30%)
- Assist with developing program and quality monitoring policies and procedures related to prior authorization of PASRR specialized services. Produce reports of findings, trends, authorization outcomes, and claims-related issues to support monitoring, process improvement, and compliance with PASRR specialized services requirements. (10%)
- Participate in work groups and TMHP LTC online portal initiatives such as user acceptance testing (UAT) on enhancements to the portal. (5%)
- Complete other work as assigned by the PASRR Policy Manager or PASRR Specialized Services Lead (5%)
Benefits
- 100% paid employee health insurance for full-time eligible employees
- a defined benefit pension plan
- generous time off benefits
- numerous opportunities for career advancement
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What This Job Offers
Job Type
Full-time
Career Level
Senior
