Job Description:

The Medicaid and CHIP Services (MCS) department is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by providing oversight to Managed Care Organizations, which deliver covered services, across delivery models, across all populations served by Medicaid and CHIP, and across all services available to individuals served by our programs.

The Public Health Prevention Specialist III is selected by and reports to the Research and Resolution Unit Manager of Managed Care Contracts and Oversight and supports various activities related to the department. Work involves coordinating the intake, assignment, and resolution of complaints and inquiries from clients, providers, advocates, and legislators about the contracted Medicaid, CHIP and Dental health plans, ensuring that the health plans comply with contract requirements and federal and state laws. This position serves as the primary department liaison with clients and providers, assisting program staff in responding to inquiries and complaints, tracking, trending, and reporting on complaint resolution statistics. Job duties will include referrals to other departments outside of managed care and collaborating with complainants and inquirers of the routing to correct area and other related job duties as assigned and as required to meet the agency mission and goals of the department. Staff in this position must work under limited supervision and with considerable latitude for the use of initiative and independent judgment.
 

Essential Job Functions:

1. Coordinates the intake and assignment of complaints and inquiries from clients, providers, advocates, and legislators about the contracted Medicaid/CHIP health plans; serves as the primary department liaison with clients and providers (50%).
2. Reviews, analyzes, and responds to routine inquiries and complaints regarding the Medicaid Managed Care Program, triages, redirects, or escalates complex cases as appropriate (20%).
3. Coordinates and maintains complaint and inquiry data, tracks, trends and reports complaint data (20%). 4. Performs other work-related work duties as assigned (10%).
 

Registrations, Licensure Requirements or Certifications:

N/A  

Knowledge Skills Abilities:

Knowledge of subsidized health insurance, including Medicaid, Medicaid Managed Care, CHIP, MCOs, contracts, policies and/or procedures.
Knowledge of contract management and compliance principles.
Analytical and organization skills and the ability to conduct investigations; gather, assemble, correlate, and analyze facts and data; and devise solutions to problems. Knowledge of state and federal laws, regulations and processes regarding Medicaid Managed Care and CHIP.
Skill in using personal computer application software such as Microsoft Word, Business Objects, Excel, Power Point, or other similar programs.

Skill in using agency programs such as TIERS, HHS Enterprise Portal, HEARTS, TexConnect and other similar applications.

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.
Ability to interpret legal documents, including contracts.
Ability to conduct in-depth investigation of complaints and inquiries.

Ability to reevaluate and develop policies and procedures.

Initial Screening Criteria:

1. Graduation from an accredited four-year college or university with major course work in a field related to health and human services generally preferred. Experience and education may be substituted for one another on a year for year basis. 
2. Experience in Medicaid, Medicaid Dental and CHIP managed care programs, policies, procedures, contracts and service delivery mechanisms is required.
3. Experience with using a personal computer and application software such as Microsoft Word, Excel, Power Point or other similar programs is required.

4. Experience in using agency programs; TIERS, HHS Enterprise Portal, TexConnect portal and other similar applications are required.