Physician II
2 weeks ago
Physician II - Medical Director for Waiver Eligibility
The Medical Director for Waiver Eligibility for the Medicaid and CHIP Services Department (MCS) serves as a senior-level clinical staff in the Office of the Medical Director (OMD) that is focused on eligibility determinations for certain Medicaid waiver programs.
MCS is driven by its mission to deliver quality, cost-effective services to Texans. OMD provides clinical consultation and guidance to other areas within MCS, throughout the Agency, and to external stakeholder organizations. It works to provide a clinical vision for improving the health of Texans by aligning MCS programs with state public health priorities. OMD also leads the utilization review team of MCS which is charged with ensuring that individuals receive medically necessary, cost-effective services.
This position reports to the Senior Associate Medical Director for MCS. The work involved is highly advanced (senior-level) clinical, consultative, and managerial work. Work includes review of clinical assessments completed by the staff of Medicaid managed care organizations (MCOs) for determination of waiver eligibility. Work also includes integrating knowledge of the Medicaid/CHIP programs with up-to-date healthcare practices and evidence-based clinical guidelines. This position may plan, assign, and/or supervise the work of others to include clinical/professional-level staff. Work also involves consultation with HHSC staff within MCS, but also across areas to include other HHSC areas as well as the Texas Department of State Health Services (DSHS). Work may also include directing clinically related training and the provision of technical assistance to HHSC staff and stakeholders as well as provide clinical guidance and interpretation of HHSC policy. The position interfaces with a variety of stakeholders and stakeholder organizations to include providers, advocates, Advisory Committees, legislators, and other policymakers. This position frequently interfaces with medical directors from other state agencies (e.g., Department of State Health Services), vendors, and Medicaid Managed Care Organizations (MCOs). This position works under minimal supervision with extensive latitude for the use of initiative and independent judgment. This critical work helps to shape policies and the delivery of comprehensive healthcare to children and adults served by HHSC.
This position may serve as Acting Chief Medical Director for MCS when the Chief Medical Director and/or the Senior Associate Medical Director are unavailable.
The ideal candidate thrives in an environment that emphasizes teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy. Essential Job Functions:
60% Performs review of assessments and associated documentation for determination of waiver eligibility. Interprets complex state and federal laws, regulations, and rules related to the program. Guides staff in the interpretation of medical policy. Provides day to day clinical guidance, support and leadership for review activities and decisions. Advises nurses and leaders in the clinical decision-making activities.
20% Represents unit at fair hearings and administrative reviews as needed. Reviews documentation generated internally and submitted from external sources as part of the proceedings.
5% Provides clinical consultation to Medicaid/CHIP and other HHSC areas and sister agencies on policies and program development for fee for service and managed care Medicaid/CHIP.
5% Interfaces with the medical directors of contractors, other state agencies, healthcare associations, and organizations representing clients. Monitors trends and makes recommendations for process improvement in systems.
5% Attends key Medicaid/CHIP internal and external stakeholder meetings.
5% Attends work on a regular and predictable schedule in accordance with agency leave policy. Performs other duties as assigned. Knowledge Skills Abilities:
Knowledge of medical methods, procedures, and trends of the principles and practices in the development.
Knowledge of the clinical practice guidelines development process and the application of said guidelines.
Knowledge of medical methods, procedures, and trends, of the principles and practices in the development, implementation, and documentation of individualized care and treatment plans.
Knowledge of principles and practices of modern medicine related to physical, developmental, and behavioral health needs of individuals including both non-pharmacological and pharmacological interventions.
Knowledge of local, state, and federal laws and regulations and of the principles of public administration and management.
Knowledge of state and federal programs that serve Medicaid and CHIP clients.
Ability to understand and effectively interpret agency and program rules, policies, and procedures.
Ability to analyze situations and develop an effective course of action.
Ability to perform policy and medical literature research.
Ability to communicate effectively orally and in writing.
Ability to work independently with minimal supervision.
Ability to interact effectively and professionally with persons from diverse cultural, socioeconomic, educational, racial, ethnic, and professional backgrounds.
Skill in the care of and treatment of patients to include use of diagnostic and treatment tools and equipment.
Skill in problem indentification, analysis, and resolution.
Skill in the use of computer software, specifically Windows, Microsoft Outlook, Word, Excel, and Power Point.
Skill in expressing ideas clearly and concisely.
Skill in written and oral scientific and medical communication.
Skill at establishing and maintaining productive working relationships both internally and externally.
Demonstration of leadership and good interpersonal relationships.
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