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Job Description
PRAA Operations-Claims Subject Matter Expert Health & Human Services Comm Austin, TX Job Details Full-time $4,263.16 - $5,521.16 a month 1 day ago Benefits Health insurance Pension plan Opportunities for advancement Qualifications Appeals Program design Program management Managed care Managed care organization experience Operations coordination Handling customer inquiries Provider enrollment for medical credentialing Collaborating with government agencies Patient complaint handling Research Medicaid health insurance Policy & process development Social services policy development Research report preparation Bachelor's degree Internal employee customer service Medical insurance appeals management Data interpretation Interdisciplinary policy and procedure development Computer skills Healthcare regulatory compliance policy development Medicaid regulations Medicaid Healthcare policy implementation Process improvement planning Senior level Training 4 years Insurance claims appeal handling Full Job Description 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.
16GX,60C0,611X,612X,63G0,641X,712X,86M0,8U000,OS,OSS,PERS,YN,YNS Program Specialist IV 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. Essential Job Functions (EJFs): 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. Knowledge, Skills and Abilities (KSAs): 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.
Registrations, Licensure Requirements or Certifications:
N/A Initial Screening Criteria:
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.
Additional Information:
Salary Note:
The salary offered will follow HHS HR Policy and Procedures. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual. For internal applicants, there can be limitations in consideration of applicant's current classification and salary and is also dependent upon available budget. Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.
Active Duty, Military, Reservists, Guardsmen, and Veterans :
Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor's Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.
ADA Accommodations:
In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.
Pre-Employment Checks and Work Eligibility:
Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks. HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9
Form Telework Disclaimer:
This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
