Specialty Health Eligibility Specialist

TX-HHSC-DSHS-DFPS•Austin, TX

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. Functional Title: Specialty Health Eligibility Specialist Job Title: Eligibility Advisor V Agency: Health & Human Services Comm Department: KHC Admin Posting Number: 14398 Closing Date: 03/16/2026 Posting Audience: Internal and External Occupational Category: Community and Social Services Salary Range: $3,581.33 - $4,476.83 Pay Frequency: MonthlySalary Group: TEXAS-B-17 Shift: Day Additional Shift: Telework: Travel: Up to 15% Regular/Temporary: Regular Full Time/Part Time: Full time FLSA Exempt/Non-Exempt: Nonexempt Facility Location: Job Location City: AUSTIN Job Location Address: 701 W 51ST ST Other Locations: MOS Codes: No military equivalent Brief Job Description: Under the general direction of the Specialty Health Eligibility Supervisor, performs advanced (senior-level) eligibility determination work for the Kidney Health Care (KHC), Children with Special Health Care Needs (CSHCN) Services Program, and the Hemophilia Assistance Program (HAP). Works under minimal supervision, with considerable latitude for the use of initiative and independent judgment. Responsibilities include determining eligibility, providing technical assistance to internal and external partners for the completion of program eligibility, and maintaining client eligibility status. Coordinates and verifies client benefits. Monitors clients to ensure compliance with rules, policies, and procedures. Makes recommendations for action based on findings. Responds to inquiries regarding eligibility determination of benefits. Conducts reviews to determine or verify new and continues program eligibility. May calculate and/or assist with process changes to client benefits such as overpayment, adjustments, or restoration of benefits. Documents case records to maintain accurate and confidential client records. Reports directly to the SH Eligibility Supervisor in SH Policy and Program Development with regard to scope of work and assignments.

Requirements

Knowledge of state and federal program eligibility guidelines, regulations, and policies; social services eligibility requirements; and community welfare resources.
Knowledge of community and government service delivery systems; Case management delivery systems; state and federal laws, case guidelines, regulations, and policies; programs which support client populations served by Specialty Health about the evaluation of eligibility; individual needs associated with special health care needs/disabilities and related community welfare resources.
Skill in interviewing, in conducting individual needs assessments, and in the use of a computer and applicable software.
Skill in interviewing and communicating with clients, case managers, and social workers for the purpose of conducting individual needs assessments; providing technical assistance to providers, clients, and professional staff; navigating interagency procedures; providing customer service support to clients and providers regarding complex eligibility requirements and benefits.
Ability to convey instructions and explanations to clients and interested parties; negotiate available services for our client population; develop and interpret policies and procedures, and to assess compliance; communicate effectively with coworkers, clients, and providers; work effectively as a team member.
Ability to maintain effective working relationships, to elicit and evaluate information, to research and investigate, to perform basic arithmetic and data analysis, and to communicate effectively.
Ability to serve as a lead worker providing direction to others.
At least two years’ experience reviewing applications and supporting documentation to determine eligibility for client service or social service programs such as Medicaid/Medicare, CHIP, or other public benefit programs.
Experience using various automated computer systems and databases to review and confirm supporting documentation for service program eligibility;
Experience in providing customer service to clients and providers regarding complex eligibility requirements and program benefits.

Nice To Haves

Experience with Medicare, Medicaid, and CHIP regulations relating to eligibility, coordination of benefits, insurance, and third-party coverage.
Experience using systems such as Phoenix, TIERS, IBIS, SharePoint, CMS Portal, etc.

Responsibilities

Determine initial and renewal eligibility for the Specialty Health (SH) programs, including Kidney Health Care (KHC) Program; Children with Special Health Care Needs (CSHCN) Services Program; Hemophilia Assistance Program (HAP); along with eligibility support with other SH programs.
Manage receipt of application and documents for eligibility determination (including proof of income, residency, identification and insurance information); collect, assess and determine if there are any missing pieces of information for determination in a timely and effective manner.
Professionally communicate throughout the determination process, as needed with social workers, case managers or client/client representatives.
Identify, verify, and validate all third-party insurance coverage’s during the application determination process.
Correctly coordinate all third-party benefits in accordance with program rules, policies, and procedures.
Submit correct coordination plan to the SH Eligibility Team's Insurance staff and verify that they have coordinated the client benefits correctly and accurately.
Uploads and organizes electronic documentation for verification and review.
Works with supervisors, other team members and SH Customer Support team to coordinate services and ensure client, social worker and case manager communication and guidance is current, accurate, professional and helpful.
Participate in team meetings, trainings and continuous improvement initiatives.
Shares best practices and assists with onboarding or training new staff when needed.
Maintain accurate case records for KHC, CSHCN and HAP clients in agency systems, ensuring all data is complete and compliant.
Ensure meeting standards for timeliness and accuracy in all client record updates and entries.
Manage assigned caseload efficiently while meeting productivity and quality standards.
Maintain confidentiality and follow all HIPAA and privacy standards.
Participate in audits, quality reviews and error-correction processes.
Keeps up-to-date with policy changes and updates procedures accordingly.
Serve as an eligibility subject matter expert to internal and external customers and other stakeholders.
Assist all stakeholders in understanding SH eligibility rules and requirements.
Offer concise answers and provides easily understandable examples of eligibility and system processes.
Attend meetings and conference calls as assigned to provide expertise and stay knowledgeable of current changes to the program by attending trainings and staying knowledgeable with updates to policy and procedure manuals.
Actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation.