Program Specialist VI

TX-HHSC-DSHS-DFPS•Austin, TX

1d•Onsite

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. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage. The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Program Specialist VI. MCS is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by performing highly advanced consultative, technical, and analytical work related to the research, development, and implementation of Medicaid medical benefits policy. This position is the Federally Qualified Health Center (FQHC), Rural Health Clinics (RHC), and Hospital Services subject matter expert and will lead on related medical policy projects and must be proactive in seeking input from other staff in the Medicaid/CHIP Division and demonstrate the ability to work as an effective team member with other divisions within HHSC, and other HHS agencies. This position must be able to research, analyze, and synthesize information such as current standards of care, evidence-based practices, and peer reviewed literature and apply findings to medical benefit policies in review. 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. The Program Specialist VI reports to one of the Medical Benefits Policy Managers. This position works under limited direction of the Manager with extensive latitude for the use of initiative and independent judgment.

Requirements

Graduation from an accredited four-year college or university.
A minimum of two years’ experience with policy analysis, health care policy or Medicaid and CHIP policy.

Nice To Haves

Experience with hospital, FQHC, and/or RHC billing or policy.

Responsibilities

Serves as the Lead in the development, planning, and implementation of complex new or current medical benefit policies. Researches, analyzes, and synthesizes medical policy documents, complicated federal regulations, client information, and complex claims processing system information for each benefit review. Identifies and provides the applicable Code of Federal Regulations (CFR), State Plan, and Texas Administrative Code (TAC) citations for policy reviews by performing technical research using online resources and electronic databases. Attends medical policy workgroup meetings and provides recommendations on medical policy information verbally or in writing.
Researches, analyzes, and synthesizes very technical information such as standards of care, evidence-based practices, and peer reviewed literature using a variety of resources and websites and applies findings to medical benefit policies. Conducts complex research on MCO benefit coverage, private payer benefit coverage, and other state Medicaid benefit coverage during the policy development process. Assists in the development and review of complicated medical policies including reviewing documentation, policy language development, tracking document research, and reviewing discussions and draft benefit policy changes. Performs complex quality review of policy language and claims processing system changes to ensure all changes are appropriate and have been captured accurately. Documents and escalates issues to the Medical Benefits Manager.
Develops complex memos, briefs and other documents for HHSC Executive Leadership regarding medical policy changes. Develops and provides recommendations for benefit coverage to HHSC Executive Leadership. Develops, submits and coordinates policy changes to Rules and the Medicaid State Plan. Collaborates with HHSC staff and other HHS agencies to oversee and provide comments on medical policies, Texas Medicaid Provider Procedures Manual, and other materials to ensure that the information is accurate and in accordance with policies and procedures. Works with external stakeholders, HHS agencies and vendors in order to resolve policy issues, discuss program effectiveness, and identify training needs.
Leads and/or participates in special medical and policy projects and provides guidance to staff in the development and integration of new benefits by reviewing documents and analyzing provider questions or concerns. Prepares technical project summaries and keeps Executive Leadership updated on projects in a timely manner. Ensures compliance with medical policies, rules and statues. Leads or participates in public meetings or workgroups engaged in research, analysis, and evaluation of policy issues or initiatives.
Performs and prepares medical policy and program materials in response to internal/external requests in a professional and timely manner. Serves as a resource for new employees and internal/external staff by providing training, direction, and guidance on the development of medical policies. Gives presentations to groups and facilitates and participates in policy meetings for internal, intra-agency, vendors, stakeholders, public, or legislature. Reviews complaints concerning current medical policies by providers and other reviewers. Works with internal and external entities to identify the need for policy changes through the analysis of claims appeals and denials, provider complaints, and prior authorization requests. Responds in timely manner to internal/external communications and requests for current medical and dental benefit policy information. Works collaboratively across MCS to identify innovative and effective solutions for clients and staff. Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.