Research and Resolution Specialist

TX-HHSC-DSHS-DFPS•Austin, TX

2d•$4,020 - $6,336•Hybrid

About The Position

The Medicaid and CHIP Services (MCS) department 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 to Managed Care Organizations, which deliver covered services, across delivery models, across all populations served by Medicaid and CHIP, and across all services available to individuals served by our programs. The Program Specialist will support the Health Plan Management section by conducting in-depth analysis of complex inquiries and complaints and composing written responses to clients, agency staff, providers, advocates and Legislators; interpreting Texas Medicaid/CHIP rules, regulations, policies, and procedures and conducting research to resolve client issues and problems; and coordinating activities between clients and members, health care providers, contractors, advocates and other agencies. The Program Specialist also evaluates contractor adherence to contracts, policies, procedures, and guidelines; serving as a resource expert, creating and promoting awareness of available Medicaid/CHIP programs other government assistance and programs, and private sector resources. The Program Specialist may review and approve member and provider materials. The Program Specialist identifies policy issues to be initiated, revised or deleted, and makes recommendations for a more effective program. This position may also support the section by tracking deliverables from Managed Care Organizations (MCOs) and reviewing member and provider communication for approval. Staff in this position must work under limited supervision and with considerable latitude for the use of initiative and independent judgment.

Requirements

Knowledge of subsidized health insurance, including Medicaid, Medicaid Managed Care, CHIP, MCOs, contracts, policies and/or procedures.
Knowledge of contract management and compliance principles.
Analytical and organization skills and the ability to conduct investigations; gather, assemble, correlate, and analyze facts and data; and devise solutions to problems.
Knowledge of state and federal laws, regulations and processes regarding Medicaid Managed Care and CHIP.
Skill in using personal computer application software such as Microsoft Word, Business Objects, Excel, Power Point, or other similar programs.
Skill in using agency programs such as TIERS, HHS Enterprise Portal, HEARTS, TexConnect and other similar applications.
Skill in written and oral communication, including the ability to make public presentations, write technical information in an understandable format, produce sophisticated research and analytical reports.
Ability to interpret legal documents, including contracts.
Ability to conduct in-depth investigation of complaints and inquiries.
Ability to reevaluate and develop policies and procedures.
Graduation from an accredited four-year college or university with major course work in a field related to health and human services generally preferred. Experience and education may be substituted for one another on a year-for-year basis.
Experience in Medicaid, Medicaid Dental and CHIP managed care programs, policies, procedures, contracts and service delivery mechanisms is required.
Experience with using a personal computer and application software such as Microsoft Word, Excel, Power Point or other similar programs is required.
Experience in using agency programs; TIERS, HHS Enterprise Portal, TexConnect portal and other similar applications is required.

Responsibilities

Receive, analyze, process and respond to inquiries and complaints pertaining to MCOs.
Enter complaints and inquiries into the HEARTS tracking system in a timely manner.
Communicate effective and professionally with the various MCOs and the HHSC staff through resolution.
Ensure compliance with contract standards and assess MCO performance relative to the Performance Dashboard or other performance measures and quality improvement goals.
Populate report templates with information from multiple sources for analysis by staff in the Medicaid/CHIP division.
On a prompt and regular basis (e.g. quarterly) participate in determining the effectives of MCO operational and contractual compliance by utilizing a standard set of assessment tools and analyzing data.
At least annually participate in identification of opportunities for improvement in MCO performance based upon consideration of performance data, stakeholder input, and HHSC priorities.
Promptly inform the Health Plan Manager of significant MCO compliance and quality improvement issues and provide recommendations for actions.
Resolve contract performance and compliance issues by working collaboratively with Health Plan Management team, the Health Plan Manager and the MCO to improve performance and contract compliance by participating in the development and monitoring of corrective action plans, as appropriate.
May also participate in the process to assess penalties or damages for failure of the MCO to meet contract performance requirements.
Review, analyze and provide feedback on MCO materials such as marketing, member and provider materials, within required timeframes with no major errors.
Collaborates with various Health Plan Management staff on MCO related complaints, such as marketing, member and provider complaints, with assigned timeframes.
Receive, analyze and process MCO member and provider materials.
Participate in functions related to special MCO projects and investigations, including but not limited to the development of and revision of MCO contract managed policy and procedures and desk reference manual.
Collaborate with contracted vendors to develop review materials, analyze and assess documents, data, and other relevant materials for special investigations, performance audits, readiness reviews, and other monitoring activities within assigned timeframes.
Coordinate with appropriate staff to develop, oversee and/or conduct surveys, inspections, reviews or other analyses to determine MCO compliance with contract, laws, regulations, policies and procedures within assigned timeframes.
Respond to governmental, commercial, and advocacy organizations regarding Medicaid and CHIP health plan issues within assigned timeframes.
Manage or facilitate special research/issues projects as assigned within timeframes.
Establish and maintain effective working relationships and communications with HHSC staff, Health Plan Management teams, MCO staff, and staff from other agencies and organizations, appropriately interact with others, provide timely responses to requests and inquiries.
Receive no more than 1-2 justified complaints per annual review period from internal or external customers regarding professional conduct, appropriate interaction with others, and/or timely responses to requests or inquiries.
Demonstrate commitment to the goals of the Medicaid/CHIP division, including showing initiative to take on new projects; being team-oriented; being committed to outstanding customer services; and being willing to think outside the box with a focus on promoting efficiencies and accountability.
Contribute to the development of the team within Health Plan Management and the Managed Care Operations section of the Medicaid/CHIP division.
Apprise supervisor of work-related incidents or situations that could be problematic to staff, the department or the agency.
Communicate with supervisor on a timely and current basis with regard to problematic situations and apply proper judgment to assure action is appropriate.