PRAA Operations-Claims Subject Matter Expert

About the role

The Texas Health and Human Services Commission (HHSC) seeks a Program Specialist IV to join the Provider Resolution and Administrative Appeals (PRAA) unit. This role is responsible for overseeing claims management, provider enrollment, and administrative appeals for the Texas Medicaid administrative contractors. The specialist will also handle customer service inquiries, provider administrative appeals, and liaison for approving provider notifications.

Responsibilities

• Performs highly technical customer service, provider education, and follow up activities for the Medicaid Program (Fee for Service and Managed Care).
• 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.
• Supports the Non-Risk Based Payment Process.
• Facilitates and coordinates with other areas within the Medicaid/CHIP Division, HHSC, and external stakeholders.

Requirements

• 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.

Qualifications

The ideal candidate should have knowledge of local, state, and federal laws related to the program area; research techniques; training and marketing techniques; and program management processes and techniques. They should also possess skill in identifying measures or indicators of program performance and the use of a computer and applicable software. Additionally, they should have the ability to gather, assemble, correlate, and analyze facts; to devise solutions to problems; to communicate effectively; and to provide guidance to others.

Skills

• Knowledge of local, state, and federal laws related to the program area;
• Research techniques;
• Training and marketing techniques;
• Program management processes and techniques;
• Identifying measures or indicators of program performance;
• Using a computer and applicable software;
• Gathering, assembling, correlating, and analyzing facts;
• Devise solutions to problems;
• Communicate effectively;
• Provide guidance to others.

Benefits

The 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. Details on the Benefits of Working at HHS can be found on the Benefits of Working at HHS webpage.

Pay

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.

Schedule

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.