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Program Specialist VI

1 month ago

Austin, United States Texas Department of Aging & Disability Services Full time
Job Description:
Program Specialist VI
The program specialist VI will act as team lead to the Provider Resolution and Administrative Appeals (PRAA) Team within Operation Management. The Program Specialist VI reports to the Manager for Provider Resolution and Administrative Appeals (PRAA). 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 for provider enrollment and claims, provider administrative appeals for claim payments, reviews of claims administration and provider enrollment, and oversees contract requirements for provider enrollment, administrative appeals, training, and claims administration.

This position will involve highly advanced (senior level) work and support to the department manager. The team lead has extensive latitude for the use of initiative and independent judgment. Tasks include but are not limited to conducting complex analysis of provider claims and administrative appeals, training staff on provider claims and appeals, researching complaints, customer service and provider education regarding Medicaid Program (Fee for Service and Managed Care). This position requires reviewing, researching, analyzing, and evaluating, and making final determinations on requests for administrative appeals related to provider payments including, Health Management Services Recovery Audit Contractor (HMS RAC) appeals, Surveillance Utilization Review (SUR) appeals, and state exception requests.

Quality assurance, and development of recommendations in response to Medicaid and Children’s Health Insurance Program (CHIP) escalated provider issues and operations identified by program providers, HHS, stakeholders, and/or the Texas Medicaid & Healthcare Partnership (TMHP); act as the subject matter expert in projects related to provider enrollment, claims, administrative appeals, and other related workgroups/meetings; act as a liaison to program staff, governmental agencies, community organizations, external and internal stakeholders, and program providers; review enrollment and appeal rules, policies, laws, regulations and procedures for contract compliance; work closely with other HHS department staff and TMHP on various assignments and projects related to provider enrollment, administrative appeals or provider issues; train, lead, assign and/or prioritize the work of others on the team; provide assistance and support to team members; identify the need to address areas of concern that may be impeding success or to achieve programmatic goals and successfully implement operational changes to completion.
Essential Job Functions:
Performs complex consultative and technical work including research, analysis, and resolution related to provider administrative appeals involving Texas Medicaid. Provides coordination between health care providers, contractors, governmental agencies, recipient, and other parties to resolve appeals related to providers of Medicaid services.
Program Specialist acts on behalf of the PRAA Manager and provides advanced guidance, effective planning, organization, training, and direction to the department’s staff. Sets goals and objectives, prioritizes assignments, provides direction, reviews, and approves work products. Oversees the staff performance of the day-to-day operations of the PRAA team.
Performs in-depth analysis of complex inquiries and complaints and composes written responses to clients, agency staff, providers, advocates, and Legislators. Interprets Texas Medicaid rules, regulations, policies, and procedures and conducts extensive research to resolve provider and client issues/problems.
Make independent decisions that will resolve complex issues across the PRAA Department and provides guidance to staff in the implementation of new methods and procedures. Specialist will determine the need for communication of issues, both laterally and horizontally among HHS and external stakeholders. Specialist will advise the PRAA Manager of any staff performance issues related to projects of the PRAA team. Specialist will escalate to leadership any issues and decisions such as high-cost technology changes, poor performance by claims administrator, and potential litigation issues with providers that will put the State at risk. Specialist will escalate concerns and issues to the manager as necessary.
Develops and implements tools to analyze and track staff and unit performance and projects using information that includes, but is not limited to performance reports, quality management reports, technical assistance and training documentation, and other pertinent data as applicable. Communicates the results and recommends actions on a routine basis to unit manager.
Leads, facilitates, and participates in provider claims and administrative appeals projects, internal and external workgroups, and provider/stakeholder meetings. Specialist participates in workgroups and public meetings regarding acute care program and policy issues, initiatives, and Medicaid program changes, and participates in special investigations, studies, and program analysis projects. Reviews, analyzes, and comments on proposed legislation, public and internal documents, and regulations affecting assigned program and policy areas and audit findings. Prepares project updates, summaries, reports, or other documents and keeps supervisor informed on pertinent issues.
Other duties as assigned.
Knowledge Skills Abilities:
Knowledge of local, state, and federal laws related to Medicaid program.
Knowledge of the relationships between customer services and medical management areas within a health management care organization.
Knowledge of public health and health care policy issues, systems of service, and programs.
Knowledge of project management methodology/tools.
Knowledge of quality improvement or quality assurance and measurement systems.
Knowledge of Medicaid TIERS eligibility system, Phoenix, Project and Portfolio Management (PPM), Customer Relation Management (CRM) and OnBase reports.
Skill in leadership, project management, and time management.
Skill in researching, developing, analyzing, and evaluating complex program and policy issues.
Skill in managing multiple and competing priorities.
Skill in meeting facilitation, problem solving and conflict resolution.
Skill in working collaboratively and cooperatively with diverse groups.
Skill in establishing and maintaining effective working relationships and ability to work cooperatively in team environment.
Ability to manage activities, establish goals and objectives, and devise solutions to problems.
Ability to prepare concise, accurate reports and communicate effectively both orally and in writing.
Ability to train, schedule, assign, and prioritize the work of others.
Ability to work collaboratively with peers to establish program goals and priorities.
Ability to identify and analyze problems, evaluate alternatives and propose effective solutions.
Ability to interpret and explain complex programs policies and procedures, and rules, regulations and guidelines.
Ability to identify problems, evaluate alternatives, and implement effective solutions.
Ability to coordinate with other staff, departments, officials, agencies, organizations, and the public.
Ability to lead workgroups, projects, and meetings.
Ability to prepare clear and concise presentations and reports.