PRAA Operations-Claims Subject Matter Expert
About The Position
Performs highly complex (senior-level) consultative services and technical assistance work. The Program Specialist IV reports to the Claims Administration Manager in the Provider Resolution and Administrative Appeals (PRAA) unit. The PRAA unit provides oversight of the Texas Medicaid administrative contractors in the areas of claims management, provider enrollment, and administrative appeals. PRAA also handles customer service inquiries, provider administrative appeals for claim payments, updates to trainings and provider handbooks and manuals, liaison for approving provider notifications related to claims, provider enrollment and administrative appeals. This position will be the subject matter expert liaison for the benefit assessment meetings (BAM) implementations. The specialist works under limited supervision with considerable latitude for the use of initiative and independent judgment. Duties include performing highly technical customer service, provider education, and follow up activities for the Medicaid Program (Fee for Service and Managed Care). The specialist reviews, interprets, and investigates complex complaints, issues, and questions received from providers, other government agencies, patient advocacy groups, legislators and other interested parties concerning policy, claims processing, and benefits of the Medicaid program. This includes supporting the Non-Risk Based Payment Process. Work involves planning, developing, and implementing major agency program(s), and providing consultative services and technical assistance to HHSC program and vendor staff. May provide guidance to others. The Specialist also ensures the proper implementation of initiatives, policies, and programs. Work involves facilitation and coordination with other areas within the Medicaid/CHIP Division, HHSC, and external stakeholders.
Requirements
- Knowledge of local, state, and federal laws related to the program area; research techniques; training and marketing techniques; and program management processes and techniques.
- Skill in identifying measures or indicators of program performance and the use of a computer and applicable software.
- 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 provide guidance to others.
- Bachelor's degree from an accredited 4-year college or university OR 4 years experience in one of the following fields: Medicaid programs, managed care, healthcare, health insurance programs, health and human services policies and procedures, complaints, or appeals. Education and experience may be substituted for one another.
Responsibilities
- Work involves facilitation and coordination with other areas within the Medicaid/CHIP Division, HHSC, and external stakeholders with a main focus on claims (30%).
- Performs an array of technical, research, planning, policy, program assessment, and administrative activities for assigned program(s) and the successful implementation of initiatives (20%).
- Collects, organizes, analyzes, and/or prepares materials in response to requests for program information and reports (15%).
- Provides input and technical assistance and guidance to staff (internal and other HHS agencies) in the development and implementation of program changes and new initiatives (10%).
- Provides advice and counsel by interpreting policies, procedures, rules, regulations, and standards related to the program (5%).
- Monitors, reviews, and evaluates compliance with program policies and procedures, statutes, and rules for assigned programs (5%).
- Evaluates research findings relative to specific projects being developed (5%).
- Reviews program area functions and operations, identifies areas needing change, and develops plans to improve programs or to address areas of concern (5%).
- Assists in developing program policies, procedures, standards, and manuals in accordance with program objectives and goals (5%).
- Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.
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
