Program Specialist IV

Texas Health & Human Services Commission Austin, TX
Program Specialist IVAssesses, develops, monitors, and implements departmental policies and federal and state regulations as they apply to reimbursement for ICFIID services. Works closely with the Supervisor of the Reimbursement and Revenue Management Unit on planning and development of residential ICFIID reimbursement programs, training Reimbursement Office staff at 13 State Supported Living Centers; ensures all claims for SSLC residents have been processed for the month; resolution of any payment discrepancies, rejected claims, and problems related with processes and policy; develops maintains, implements, and interprets policies, procedures, and guidelines on administration, billing, and collection of Medicare Parts B and D, Medicaid, other Third-Party sources at ICFIID SSLCs. Provides instruction and guidance to Program Specialist II staff in the unit to ensure policy requirements are followed and objectives are accomplished. Reviews federal policies related to Medicare billing and collections and relates information to SSLCs to ensure practices meet guidelines in place. Consults with and advises supervisory and administrative staff regarding complex revenue management problems/actions.Essential Job Functions:

Actively monitors status of denied Medicaid eligibility cases and initiates corrective action with HHSC on problems as needed. Advises Reimbursement field staff on necessary action to obtain Medicaid eligibility and prevent loss of revenue. Performs research on case-specific and general matters related to obtaining Medicaid and/or Medicare eligibility for individuals through record reviews and interagency contacts.Analyzes and prepares reports of operations and collections for internal use and interagency distribution.Analyzes, evaluates, advises and assists Reimbursement staff on determining corrective action needed on rejected and denied claims. Requires an enhanced understanding of Medicaid and other third-party billing and payment processes.Assists in the development of reimbursement program goals and objectives; develops and recommends program guidelines, procedures, policies and rules. Assists in setting priorities and program standards for achieving goals and objectives. Assists in evaluating effectiveness of program activities and other duties as assigned to achieve maximum reimbursement. Coordinates activities of the Reimbursement and Revenue Management SSLC Section at the request or during the absence of the Manager of the section.Establishes and maintains liaison with representatives of CMS, Medicare, TMHP, Medicaid and state HHS staff to assist in the coordination, development and implementation of reimbursement programs to support the goals of HHS and Reimbursement and Revenue Management.Develops and edits training, operational, and educational materials for ICF SSLC Reimbursement programs statewide, including manuals for Medicare Part B Guidelines for Documentation, and Reimbursement Policy and Procedures for campus-based and state-operated community-based ICF/IID programs. Functions as Part B Policy Specialist/Subject Matter Expert.Prepares materials for site-visits or desk reviews and conducts thorough review and evaluation of Reimbursement Office procedures and work.Provides incident-specific technical advice and trouble-shooting to field offices by phone. Requires thorough working knowledge, enhanced understanding, and ability to perform all SSLC Reimbursement manager tasks including all aspects of ICF SSLC Reimbursement Office procedures including PC-ACE PRO32 software for Medicare Part B filing and mainframe Claims2.Researches and provides data to answer questions from other areas to include Policy, Cost Reporting, SSLC facilities, and auditors. Coordinates with SSLC administration and SSLC state office for information and dissemination of data and procedures for actions to include Medicare Part B enrollment. Provides directive to SSLC facilities regarding Medicare Part B audits. Analyzes results and works with staff on corrective actions. Provides summary to SSLC state office.Reviews and corrects reports and information for distribution to various departments, agencies, individuals, and field offices to include the ICF Summary. Requires contact with Department personnel on correct inventory of certified bed counts and contact with Reimbursement field staff to verify correct status of individuals not on the Medicaid bill.Trains field office personnel on SSLC Reimbursement policies and procedures through site visits, annual conferences, phone contacts, and teleconferences.Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.Knowledge Skills Abilities:

Knowledge of state and federal laws related to third-party programs such as Medicare, Medicaid, and private health insurance. Knowledge of health related accounting and collection procedures. Knowledge of medical claims submission and reconciliation. Knowledge of Medicare Provider Enrollment process.Advanced skill in using computer software, including but not limited to Outlook, Word, and Excel. Skill in effectively managing, reconciling and/or reporting accounts receivables. Skill in developing and/or implementing complex reporting specifications. Skill in communicating effectively verbally and in writing. Ability to gather, correlate and analyze state and federal rules, regulations, policies and procedures. Ability to perform mathematical computations. Ability to learn mainframe systems such as Claims2 and CARE. Ability to train others. Ability to establish and maintain effective working relationships with others. Registration or Licensure Requirements:

NoneInitial Selection Criteria:

Knowledge of Medicaid and Medicare Part B reimbursement. Experience in medical claims filing. Experience in account collections and reconciliation procedures. Experience using Word, MS Outlook, and Excel. Knowledge of Texas Integrated Eligibility Redesign System. Experience in writing instructional material.Graduate from an accredited four-year college or university preferred. Job related experience may substitute for college degree. Additional Information:

NOTE: When completing your application, include details about your job experience as it relates to the essential functions, knowledge/skills/abilities, and screening information provided on this Position Description. Req #384251MOS Code:

Note: There may be no military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position. All active duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information see the Texas State Auditor's Military Crosswalk at

HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

I-9 Form - Click here to download the I-9 form.

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.

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