Community Care Worker III

6 months ago

Abilene, United States Texas Department of Aging & Disability Services Full time
Job Description:
Serves as a specialist in the Program Support Unit (PSU) performing moderately complex tasks related to managed care Long Term Services and Supports (LTSS). Work involves frequent contact with case managers in Community Care Services Eligibility (CCSE), individuals enrolled in or applying for (c) waiver services, service providers, LTSS MCOs, relocation specialists, nursing facility staff, the public, Health and Human Services Commission, Managed Care Compliance and Operations, Health Plan Management, and Medicaid for the Elderly and People with Disabilities (MEPD) staff. Works under general supervision with moderate latitude for the use of initiative and independent judgment. Work includes operating a computer and requires an extensive knowledge of CCSE/PSU programs and software.

Duties include case management activity, for example helping people select a managed care organization (MCO), approving and denying eligibility for a Medicaid waiver program, playing a key role in transitioning individuals from nursing facilities to the community (Promoting Independence), entering or validating waiver eligibility records in authorization systems, notifying members of Medicaid Waiver program eligibility, managing fair hearing request for Medicaid Waiver program denials, transfer of Medicaid waiver program cases, and coordinating the aging out process for individuals enrolled in the Medically Dependent Children Program (MDCP).
Essential Job Functions:
Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Develop, coordinate, and explain Medicaid waiver programs to applicants and members. Authorize or deny waiver services, by sending approval or denial notices to applicants, members and other key parties. Validate eligibility in appropriate systems. Register waiver program eligibility in appropriate systems, authorize MCOs to begin approved services. Coordinate with MEPD staff for enrollment in a Medicaid Waiver program. (50%)

Perform interest list activities such as confirming contact information is accurate, mailing enrollment packets, determining which MCO individuals want to enroll with, making follow-up contacts as needed, and ensuring individuals’ wish to be assessed for a Medicaid Waiver program. (10%)

Interpret policy and coordinate activities related to transitioning individuals from the nursing home to the community, handling the transition of children aging out of MDCP services, and people who transition in and out of a Medicaid Waiver program. (10%)

As appropriate, contact the appropriate person to assist with resolution of obstacles and document the reason for the delay. (5%)

Handle continuum of care issues related to LTSS for Medicaid waiver members who have been disenrolled or transferred in or out of managed care service areas and are experiencing a gap in services. This could include coordinating with CCSE and between MCO’s as appropriate. (10%)

Assist Medicaid Waiver members who have been denied services to file a fair hearing with the state. Track and monitor appeal processes through to the decision. (5%)

Handle duties such as complete reports to monitor program operations, research and resolve errors in enrollment and make referrals to MEPD for members who lose Supplemental Security Income (SSI) eligibility. (10%)

Knowledge Skills Abilities:
Knowledge of Medicaid waiver programs, policies and procedures. General knowledge of community and government service delivery systems, case guidelines, regulations and policies, interviewing techniques, mental illness and the emotional components of physical illness, individuals’ needs associated with disabilities, and community welfare resources. Skill in communicating effectively orally and in writing with all types of people, in all types of situations. Ability to convey instructions and explanations to individuals and key parties, to negotiate available services, and to train others. Ability to operate computer equipment and be proficient in the use of Outlook, Excel, Word, as well as the ability to gain a general understanding of various state software programs, e.g., TIERS, SAS and CSIL. Skill in managing stress in high-profile situations while maintaining a professional demeanor. Skill in identifying systemic problems and ways to resolve same. Skill and ability to multi-task under pressure. Skill and ability to manage workload effectively to meet goals and objectives of Medicaid waiver programs and meet timeframes. Ability to identify potential problems that would have a negative impact on service delivery and act proactively to prevent the problem. Ability to establish priorities according to relative importance and deadlines, set goals and manage time efficiently.

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