Program Specialist V

Job Description : Program Specialist V

Program Specialist V

The HHSC Medicaid CHIP Services (MCS) division seeks a highly qualified candidate to fill the position of Program Specialist V, Operational and Readiness Review Specialist.

MCS is driven by its mission to deliver quality, cost-effective services to Texans. The Operational and Readiness Review Specialist makes a significant contribution to MCS’s mission by ensuring operational readiness of the managed care organizations and their compliance with established policies, rules and regulations.

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.

The Operational and Readiness Review Specialist reports to the Senior Manager of the Operational and Readiness Review Team in the Managed Care Contracts and Oversight (MCCO) Medicaid / CHIP Services Division.

This position requires the necessity to travel monthly for operational reviews and as well as at a moment's notice based on significant MCO non-compliance.

Position will perform highly complex consultative services and technical assistance work. Work involves leading operational and readiness initiatives such as claims system changes, readiness reviews, operational reviews and targeted reviews.

Work involves planning, developing, and implementing major agency program(s) and providing consultative services and technical assistance to program staff, governmental agencies, community organizations, or the general public.

Work also includes research and developing tools for reviews. Position will work in partnership with HHS program staff and contracted Managed Care Organizations (MCOs).

Work includes evaluating MCO adherence to contracts, policies, programs, other government assistance and programs and private sector resources.

Position will apprise Senior Manager of work-related incidents or situations that could be problematic to staff, the department or the agency.

Position will communicate with Senior Manager on a timely basis with regard to problematic situations and apply proper judgment to assure action is appropriate.

Position works under limited supervision and with considerable latitude for the use of initiative and independent judgment.

Essential Job Functions :

1. Ensure compliance with contract standards and assess MCO performance by reviewing MCO contract deliverables, performance measures and MCO compliance with state and federal regulations.

a. On a prompt and regular basis determine the effectiveness of MCO operational and contractual compliance by utilizing a standard set of assessment tools.

b. Promptly inform the Senior Manager of significant MCO compliance and performance issues and provide recommendations for action.

c. Facilitate collaboration with other MCCO staff, the MCO, and other external / internal stakeholders to ensure contractual compliance by developing, monitoring, and updating action plans.

d. Work promptly and collaboratively to assess and review recommended remedies for noncompliance of contractual requirements.

e. Collaborate with MCCO Research and Resolution promptly and timely on escalated MCO related issues.

f. Respond to and review legislative, open records and audit requests within specified timeframes.

2. Lead and facilitate functions related to operational on-sites, desk reviews, implementations, readiness reviews, information sessions, or other activities as required.

a. Manage or facilitate special research / issues projects as assigned within timeframes.

b. Develops materials and prepares reports based on findings from readiness reviews.

3. Establishes and maintains effective working relationships and communications with HHS staff, and other internal / external stakeholders, and provide timely responses to requests and inquiries.

a. Receive no more than 1-2 justified complaints per annual review period from internal or external customers regarding professional conduct, appropriate interactions with others, and / or timely responses to requests or inquiries.

4. Demonstrates commitment to the goals of the Medicaid / CHIP services, shows initiative to take on new projects, is team-oriented and committed to outstanding customer service, and focuses on promoting efficiencies and accountability.

5. Communicates with manager in a timely manner regarding problematic situations and applies proper judgment to ensure action taken is appropriate.

6. Attends work on a regular predictable schedule in accordance with agency leave policy. Performs other duties as assigned, timely and accurately.

7. Participates in the development of RFPs and the evaluation of RFP responses within assigned timeframes. Reviews, analyzes and evaluates rules, bills and federal / state laws with implications for the Medicaid and CHIP programs as required.

Knowledge Skills Abilities :

1. Knowledge of subsidized health insurance, including Medicaid, Medicaid Managed Care, and / or CHIP.

2. Knowledge of contract management and compliance principles.

3. Ability to work under limited direction and to use initiative and independent judgment.

4. Analytical and organizational skills and the ability to conduct investigations or audits; gather, assemble, correlate, and analyze facts and data;

and devise solutions to problems.

5. Knowledge of state and federal laws, regulations and processes regarding Medicaid Managed Care and CHIP.

6. Skill in using personal computer application software such as Microsoft Word, Excel, Power Point, or other similar programs.

7. Skill in written and oral communication, including the ability to make public presentations, write technical information in an understandable format, produce sophisticated research and analytical reports.

8. Ability to research and evaluate policies and procedures.