Responsible for performing eligibility determination functions for the programs administered by Purchased Health Services Unit, including the Kidney Health Care (KHC) Program, the Children with Special Health Care Needs (CSHCN) Services Program, and the Hemophilia Assistance Program (HAP). Responsibilities include determining eligibility, providing technical assistance for the completion of program eligibility, and maintaining client eligibility status. Uses various program systems including the Automated System for Kidney Information Tracking (ASKIT) and the CSHCN Management Information System (CMIS). Coordinates and verifies recipient benefits. Monitors providers and recipients to ensure compliance with rules, policies, and procedures. Makes recommendations for action based on findings. Responds to inquiries regarding eligibility determination of benefits.
Essential Job Functions:
Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.
(30%) Approve or deny submitted applications for benefits for KHC or HAP. Return or suspend applications for further action that are incomplete or lacking acceptable supporting documents. Interpret and apply rules, policies and procedures throughout the eligibility process for CSHCN, HAP, and KHC. Verify that information and supporting documentation used for eligibility determination is correct and in compliance with requirements. Provide technical assistance to providers, social work, or departmental regional staff to complete applications and maintain eligibility status. Research, verify, and update recipient information in respective program systems for the adjudication of claims and eligibility. Establish recipient vendor payee information.
(25%) Coordinate recipient benefits to ensure that all third party benefits are utilized and federal funds are maximized. Research, analyze and verify all third party resources including Medicare, Medicaid, Children’s Health Insurance Program (CHIP), private/group insurance, military, Veterans Administration health benefits using available sources, such as regional and local Social Security Administration offices for Medicare benefits, Health and Human Services Commission (HHSC) eligibility systems for Medicaid benefits, statistical /informational reports, verbal and written communication from insurance companies, and social workers. Verify that payments of benefits are made in accordance to the rules and policies. Identify other third party programs for which the recipient is eligible to receive benefits and make referral to those programs.
(25%) Perform compliance reviews and conduct investigations of applications and supporting documents to assure compliance with rules, policies, procedures and contracts. Conduct reviews and investigations via phone and fax with providers and regional staff. Make recommendations for actions of modification or suspension of benefits based on findings. Make referrals for refunds and recovery of funds to Unit auditor. Report findings of noncompliance to group manager for corrective action and decisions.
(10%) Provide technical and general information regarding application process and benefits to internal and external customers by reference and application of rules, policies and procedures. Participate in conference calls with regional staff, identify and refer problems of electronic submission of applications to automation staff for correction.
(5%) Perform special assignments as requested and other duties as assigned such as processing recipient warrants; and answering the 1-800 customer service line, responding to customer inquiries such as claim and application status.
(5%) Others duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.
Knowledge Skills Abilities:
List the knowledge, skills, and abilities critical to performance in this position:
Knowledge of agency regulations and department policies and procedures and the ability to interpret them.
Knowledge of State and Federal regulations such as Social Security Administration Disability Benefits, Medicare, Medicaid, CHIP, and Medicare Chronic Renal Disease coverage.
Knowledge of the vendor set-up portion of the State Comptroller system.
Knowledge of Health and Human Services Commission (HHSC) eligibility systems.
Skill in use of Microsoft Office Suite (MS Outlook, Word, and Excel).
Organizational and analytical skills.
Skill in communicating effectively both verbally and in writing.
Skill in providing quality customer services to clients and providers on complex eligibility requirements and benefits.
Skill in eligibility determination for health or human services related benefits.
Skill in documention verification for health or human services related benefits.
Skill in coordinating program benefits with third party resources.
Ability to understand and interpret statutes, regulations and rules.
Ability to research, analyze, and interpret information and resources for eligibility determination.
Ability to utilize and navigate complex automated eligibility systems.
Ability to effectively communicate with co-workers, clients, and providers in a clear, courteous, and professional manner.
Ability to work effectively as a team member and in work groups to achieve the goals of the section and unit.
Ability to work and make judgements independently.
Registration or Licensure Requirements:
Current Texas Driver’s License for the appropriate type vehicle.
Initial Selection Criteria:
Experience verifying private or group health insurance.
Experience in eligibility determination for health care benefits.
Experience working with Social Security Administration disability, Medicare, Medicaid, CHIP, or any other governmental eligibility health policies and procedures.
* Notice to applicants: Due to budget constraints, please note: Hiring salary will be at the base of the salary range, unless the candidate is internal, in which case a 7% may be applied for a promotion, or a 3.4% may be applied when the candidate is in the same salary group but different class title and job code.
Employee must provide transportation. If employee operates a personal or state motor vehicle in any of their official duties, the employee must possess a current valid Texas driver’s license for the state vehicle. Employees/Applicants are responsible for providing a copy of their driver’s license prior to employment
In compliance with the Americans with Disabilities Act (ADA), HHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS employee service center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.
Texas Health and Human Services Commission - 17 months ago