Ombudsman I

Job Description:
Ombudsman I
This call center position will telework % from anywhere in Texas. Under the direction of the Managing Ombudsman of the Ombudsman Complaint Services Team, the Ombudsman I will assist in resolving or mediating various types of grievances, disputes or complaints related to HHS programs. Work involves assisting the general public with information and resolution of moderate to complex issues via the Office of the Ombudsman toll-free lines, e-mail, online submissions, faxes and letters. Advises on and explains relevant state and federal rules, regulations, programs, and procedures. Triages and resolves issues and complaints by initiating investigations, researching HHS eligibility and enrollment systems and policy to determine program compliance, explaining policy and rules, and making referrals and/or escalations as needed. Provides education to HHS clients regarding the appeal and Fair Hearing process. Receives and reviews issues and complaints from clients, providers, government agencies, advocacy groups, and other stakeholders. Identifies issue and problem trends and alerts management and provides recommendations for resolution. Assists with the coordination of workflow to ensure effective delivery of services. Documents all issues and actions in a database. Tracks case information and case actions in a database. Responds verbally and in writing to clients. Works under moderate supervision, with limited latitude for the use of initiative and independent judgment.
Essential Job Functions:
EJF 1. On a daily basis, follow unit procedures to provide courteous and professional service on all contacts received by the general public, providers, advocacy groups, HHS program areas, Texas Department of Criminal Justice (TDCJ) inmates, and other stakeholders. Resolve moderately to complex issues and complaints by:
• Performing in-depth analysis of moderate to complex issues and complaints which includes: researching and interpreting state and federal rules and regulations, agency procedures, and client rights and responsibilities, including Texas Works and Medicaid for the Elderly and People with Disabilities handbooks, as well as other HHS programs; interpreting client specific information in HHS and vendor eligibility and enrollment systems, and researching the internet; and determining whether a complaint may be handled within the initial contact or requires escalation for the purpose of investigation.
• If upon research, additional issues/errors are identified, escalate the issue/error to Ombudsman III staff or HHS program areas to be addressed and make recommendations of actions to achieve final resolution. Requests responses regarding complaints from HHS program staff, including prompting for responses to determine final resolution of complaints.
• Making initial contacts by phone or in writing to HHS clients, providers, HHS program areas, Managed Care Organizations, advocacy organizations, HHS vendors, and/or local resources to mediate resolutions of issues and complaints.
• Making determinations regarding program and policy compliance.
• Escalating complex issues that cannot be resolved within initial contact to Ombudsman III staff with recommendations for actions to achieve final resolution.
• Providing accurate and appropriate information and referrals to HHS clients regarding other HHS program areas and vendors, other state agencies, and local resources.
• Educating and advising the general public and stakeholders on HHS programs and services, procedures, state and federal rules and regulations, the Fair Hearing and appeal process, and empowering HHS clients to navigate the HHS system and advocate for themselves when possible.
(35%)
EJF 2. On a daily basis, conduct intake of issues and complaints received by HHS clients, TDCJ inmates, providers, advocacy groups, other HHS program areas, and other stakeholders. Take calls on a statewide toll-free helpline, and respond to emails, online submissions, faxes and letters. Prepares and sends acknowledgments via email while complaints are being processed. Maintain production by handling share of incoming contacts within established guidelines and requirements and adhering to scheduled work activities. (40%)
EJF 3. On a daily basis, accurately and thoroughly document all issues, actions, analysis, findings, and resolutions in the Ombudsman database. (20%)
EJ4. Report to Ombudsman management recurring issues and problem trends that may affect the administration of HHS programs management, with recommendations for improvement to include HHS policy/procedure changes, changes to TAC, or vendor contract changes. (5%)
EJ5. Other duties assigned
Knowledge Skills Abilities:
a. Knowledge of health and human services programs, services and procedures.
b. Knowledge of applicable rules, regulations, policies, and functions of the Commission
c. Skill in working on an Automated Call Distribution (ACD) hotline.
d. Skill in communicating effectively both verbally and in writing.
e. Skill in establishing and maintaining effective working relationships, including the ability to work with people under pressure, and resolve conflicts.
f. Skill in using eligibility and claims databases.
g. Skill in conducting research and complaint resolution.
h. Skill in analyzing and preparing documents, reports and correspondence.
i. Skill in researching complaints and recognizing and resolving problems.
j. Ability to determine the complexity of the issue and triage to the appropriate agency or program.
k. Ability to conduct research using the Internet and other sources.
l. Ability to interpret, and apply agency, state, and federal rules, regulations, policies and procedures.
m. Ability to use an automated tracking system.
n. Ability to work and communicate with individuals in personal crises and in confrontative situations as evidenced by the ability to maintain control of an interview.
o. Ability to elicit factual information or perform required duties in order to prepare for an investigation.
p. Ability to interact with all clients, internal and external, using empathy and compassion.

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