Program Specialist VI / LON Lead

Texas Health & Human Services Commission•Austin, TX

9d•$5,099 - $8,305•Hybrid

About The Position

The LON Lead/ Program Specialist VI - Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department under the Office of Medical Director 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 providing oversight and monitoring of provider requirements with Individual Plans of Care (IPC), and Level of Care/Level of Need (LOC/LON) determinations. Under supervision of the LON Manager III of the Intellectual/Developmental Disability (IDD) Waivers, Community Services/Hospice/Utilization Review Unit, Utilization Management and Review Section, Medicaid and Chip Services of Health and Human Services; the LON Lead position performs highly advanced (senior-level) consultative services and technical assistance. Work involves planning, developing and implementing departmental and agency programs and providing consultative services and technical assistance to HHSC program staff, HHSC management staff, contracted entities, local intellectual and developmental disability authority (LIDDA) staff, the Home and Community-based Services (HCS), Texas Home Living (TxHmL), and Intermediate Care Facility (ICF/ID) provider base, advocacy groups, stakeholders, and program participants and their families. Serves as lead worker providing direction to reviewers completing desk reviews of Individual Plans of Care (IPC) and Levels of Need (LON) in compliance with HHSC rules, policies and procedures related to IPCs and LONs. Assists in preparation of hearing packets and scripts and attends fair hearings to support reviewers or cover hearings when staff are not available. Testifies on behalf of the agency in administrative hearings due to LON denials. Evaluates IPC and LON submissions to provide analysis of trends to resolve technical problems, identify opportunities for improvement and to make recommendations for improvements in utilization review processes. Staffs cases and reviews correspondence for reviewers and nurses. The LON Lead works under limited supervision with considerable latitude for the use of initiative and independent judgment. 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.

Requirements

Knowledge of the field from graduation from an accredited four-year college or university with a degree in human services or a related field with a minimum of one year of experience with persons with intellectual/development disabilities or related conditions required (to meet the requirements of a QIDP).
Knowledge of utilization review and / or HCS, TxHmL, CLASS, DBMD and ICF/ID program rules, service array and billing guidelines, local authority functions and waiver service system.
Awareness of federal and state laws relating to long term care and other Medicaid and non-Medicaid services and programs.
Skill or experience with public speaking or testifying in hearings.
Ability to communicate effectively, both orally and in writing.
Ability to multi-task, handle stress and meet deadlines.
Ability to operate computers and experience using Microsoft Office products.
Qualification as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required.
Qualification as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required.
At least two years of experience working with persons with intellectual/disabilities or related conditions preferred.
At least one year of experience of utilization review, or HCS, TxHmL, CLASS, DBMD and / or ICF/ID program rules, service array and billing guidelines, local authority functions and / or experience in the waiver service system.

Responsibilities

Reviews Level of Need requests tied to provider reimbursement for the Home and Community-based Services (HCS), and Texas Home Living (TxHmL) programs, as well as for persons in Intermediate Care Facilities for persons with Intellectual or Developmental Disabilities (ICF/IID). A change in level of need can be requested by a person’s service planning team at any time and will be reviewed by the Program Specialist VI. Serves as the lead for challenging case reviews. 40%
Consults with public and private agencies involved with HCS, TxHmL and ICF/IID to resolve problems, identify training needs, and discuss outcomes of Level of Need reviews. IDD UR is responsible for providing education and technical assistance to both external and internal stakeholders for Level of Need requests, especially for cases that result in denial or authorization of an LON at a level lower than the requested LON. 20%
Ensures compliance with program policies and procedures, statutes, and rules; and takes corrective action(s) as needed. 10%
Serves as a lead for the Level of Need team and provides feedback and guidance to program staff regarding challenging reviews and cases. Requirements may also include providing technical assistance to internal staff, external stakeholders and families on the LON process, submission standards, and rules and regulations guiding the program and LON. Covers the LON team when the Manager III is out of the office. 10%
Serves as a Subject Matter Expert and attends meetings with other program areas including Long Term Services and Supports Policy, Local Intellectual and Developmental Disability Authority (LIDDA), Contract Accountability and Provider Monitoring (CAPM), Provider Claims Services, etc. tied to LON review outcomes and provider reimbursement rates. 10%
Assists with responses to legislative, ombudsman and other external inquiries or complaints including writing well written responses. Tracks trends to determine needs for developing and revising program or policy needs. Develops and revises program manual content. Escalates concerns to manager/ director for concerns that may impact HHSC or executive leadership. Assists the manager with assigning LON assignments, external stakeholder inquires, and other duties as assigned. 10%