Job Description

The Program Specialist V reports to the Manager of Medical and Dental Benefits Policy. The Program Specialist V performs complex analysis of medical benefits in the Medicaid/CHIP Policy Development Unit. This position requires excellent writing skills and strong research skills and will lead on medical benefit policy reviews. This position is expected to understand state and federal Medicaid and CHIP laws and regulations. This position works under limited direction of the Manager with extensive latitude for the use of initiative and independent judgment. Essential Job Functions:

(30%) Researches, analyzes, and synthesizes Medicaid medical benefit policy, complicated federal and state regulations, client information, and claims processing information for each medical benefit review. Identifies the applicable Code of Federal Regulations (CFR), State Plan, and Texas Administrative Code (TAC) citations for medical benefit reviews by performing technical research using online resources. Conducts research on managed care organization (MCO) benefit coverage, private payer benefit coverage, and other state Medicaid benefit coverage during the policy development process.

(30%) May lead in the development, planning, and implementation of new or current medical benefit policies. Researches, analyzes, and synthesizes very technical information such as standards of care, evidence-based practices, and peer reviewed literature using a variety of resources and websites and applies findings to medical and dental benefit policies. Leads medical policy meetings and participates in policy discussion by providing comments and recommendations orally or in writing. Develops, submits, and coordinates policy changes to TAC Rules, the Medicaid State Plan, and/or Medicaid waivers. Performs quality review of policy language and claims processing system to ensure all changes are appropriate and have been captured accurately. Serves as a subject matter expert on current Medicaid benefits for Medicaid medical policy for HHSC internal staff, HHS agencies, stakeholders, providers, and the public.

(15%) Leads or participates in public meetings or workgroups engaged in research, analysis, and evaluation of medical benefit issues or initiatives. Acts as the liaison with HHSC staff and other HHS agencies by providing complex technical assistance and guidance on medical benefit changes during workgroups and meetings. Collaborates with HHSC staff and other HHS agencies to ensure that medical benefits information in the Texas Medicaid Provider Procedures Manual (TMPPM) and other Medicaid materials is accurate and in accordance with policies and procedures. Participates in Post Implementation Utilization Report (PIUR) meetings for medical and dental policies in order to identify if additional benefit changes are necessary and provides guidance and advice on how to implement these changes.

(15%) Develops, reviews, and provides comments on Medicaid materials intended for use by vendors, providers, and MCOs. Responds in timely manner to internal/external communications and requests for current medical and dental benefit policy information. Prepares policy updates, summaries, reports, or other documents and keeps management informed of pertinent issues. Works with internal and external stakeholders to identify the need for policy changes through the analysis of claims appeals and denials, provider complaints, and prior authorization requests.

(10%) Develops complex memos, briefs, and other documents for HHSC Executive Leadership regarding medical benefit changes. Develops and provides recommendations for benefit coverage to HHSC Executive Leadership. Supports team members in the development of medical benefit policy. Other duties, as assigned, include but are not limited to actively participating in or serving in a supporting role to meet the agency's obligations. Knowledge Skills Abilities:

* Knowledge of health and human services agencies and programs, and state and federal Medicaid and CHIP laws and regulations.

* Strong skills in analyzing and evaluating complex federal and state legislation.

* Skill in researching, analyzing, and synthesizing medical policy, claims processing system, and program issues.

* Highly organized and the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.

* Strong skill in developing and evaluating policies and procedures, assessing risks, and making recommendations.

* Strong skills in written and oral communication, including the ability to make public presentations, and write technical information in an understandable format.

* Skill in project planning, evaluation, and implementation.

* Ability to effectively facilitate meetings and maintain working relationships with staff or program stakeholders.

* Ability to exercise creative problem-solving techniques in a highly complex environment.

* Ability to work cooperatively as a team member in a fast-paced, deadline-orientated environment.

* Ability to work independently and perform work with a high degree of attention to detail.

Proficient in the use of Microsoft Office products.

Registration or Licensure Requirements:

Initial Selection Criteria:

Graduation from an accredited four-year college or university. A minimum of two years of experience with policy analysis, health care policy, and/or Medicaid/CHIP policy, or two years of work in a related area with transferrable skills. Previously or currently serving as an intern in Medicaid/CHIP Services, or completion of a master's degree in a related field, may be substituted for two years of policy analysis experience. Additional Information:

Applicants selected for an interview will be required to submit a resume, a professional or academic writing sample, and may be asked to complete an in-basket exercise.

Salary Note: The salary offered will follow HHS HR Policy and Procedures. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual. For internal applicants, there can be limitations in consideration of applicant's current classification and salary and is also dependent upon available budget. Only complete applications will be considered.

MOS Code:

Note: Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to: 230X. 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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