Opsh Eligibility Worker

Texas Health & Human Services Commission Austin , TX 78719

Posted 2 months ago

Human Services Spec V

Performs highly complex eligibility benefit coordination and administration activities for the Office of Primary and Specialty Health (OPSH), including primary and specialty health programs. Plans, implements, coordinates and evaluates all activities relating to the provision of benefits and third party coverage.

Updates and maintains coordination processes and desk references and may help Team Lead and Manager modify procedure manuals relating to benefit coordination (Medical, Drug, and Travel). Coordinates monitors and evaluates the operational processes between OPSH and other contracting and government entities. Works closely with internal/external eligibility staff to insure proper input of third party coverage into eligibility and payer systems.

Performs complex data entry, research, and verification of information which may require the use of internal and external benefit and eligibility systems.

Performs routine and special projects, research, and analysis of benefit utilization and eligibility determination. May supervise the work of others. Works under limited supervision, with considerable latitude for the use of initiative and independent judgment. Essential Job Functions:

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned

(40%) Plans, implements, coordinates and evaluates all activities relating to the provision of benefits and third party coverage. Coordinates, monitors and evaluates the operational processes between OPSH and other contracting and government entities including Medicaid, Texas Medical Healthcare Partnership (TMHP), Vendor Drug Program (VDP), Medicare, Children's Health Care Insurance Plan (CHIP), and/or private insurance companies.

Maintain, update, and verify client records in the Integrated Business Information System (IBIS), process termination for client records, and review work of regional staff on third party coverage. Works closely with internal/external eligibility staff to insure proper input of third party coverage into eligibility and payer systems.

(30%) Serves as a lead worker for the coordination of benefits for the eligibility group, which includes distributing and verifying coordination work assignments of the Administrative Assistant(s) position within eligibility. Assists with training and systematic review of activities performed in both internal and regional eligibility sites.

Supports the Human Services Specialist VII eligibility workers in third party coordination for eligibility determination, as well as additional duties as assigned by Team Lead or Manager. Works under limited supervision with considerable latitude for the use of initiative and independent judgment.

(20%) Performs complex data entry, research, and verification of information which may require the use of internal and external benefit and eligibility systems.

Performs routine and special projects, research, and analysis of benefit utilization and eligibility determination. Updates and maintains coordination processes and desk references and may help Team Lead and Manager modify procedure manuals relating to benefit coordination (Medical, Drug, and Travel). Prepares reports including graphs, charts and tables.

(5%) Serves as a representative for the eligibility group to coordinate benefits with program contractors and state health programs.

(5%) Additional duties as assigned.

Knowledge Skills Abilities:

List the knowledge, skills, and abilities critical to performance in this position:

Knowledge of health care service delivery systems and programs for specialized populations.

Knowledge of and ability to interpret state and federal laws, regulations, rules, and policies related to the programs administered by the Office of Primary and Specialty Health.

Knowledge of Medicare, Medicaid, and CHIP regulations relating to eligibility, coordination of benefits, insurance, and third party coverage.

Knowledge of computer applications and data management, such as sending secure email and navigating network folders.

Skill in using computer systems, electronic mail systems, Microsoft Office Suite (Outlook, Word, Excel, Power Point), statistical programs, Internet Explorer, Access databases or equivalent.

Skills in understanding and conveying complex processes, including verbal and written communication regarding complex issues.

Skills in providing quality customer service to clients and providers regarding complex eligibility requirements and benefits.

Skill in coordinating processes for exchange of client data with internal and external entities.

Ability to perform advanced analyses and interpretation of benefits, regulations, legislation and laws.

Ability to establish and maintain effective working relationships; to distribute and verify work assignments, address groups effectively, express ideas clearly and concisely, and to exercise good judgment in evaluating situations and making recommendations.

Ability to create and develop standard and special reports including using software programs.

Ability to work effectively as a team member and work in groups to achieve the goals of the section and unit.

Ability to create and implement trainings for internal and external stakeholders regarding processes and procedures.

Ability to effectively communicate with co-workers, clients, and providers in clear, courteous, and professional manner.


Registration or Licensure

Requirements:

None Initial Selection Criteria:

Experience using different computer automation eligibility or payment systems.

Experience researching and updating client records on eligibility, private or group insurance health coverage.

Experience using computer applications, data management, and electronic mail systems.

Additional Information:

REQ 445738

Incomplete applications may not be considered.

Additional Consideration will be given to applicants who:

Are Bi-Lingual English and Spanish

Have 2+ years eligibility experience

MOS Code:
4C0X1 Mental Health Service, 42SX Clinical Social Worker; 4C Medical; 42 Medical-Biomedical Clinicians

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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Opsh Eligibility Worker

Texas Health & Human Services Commission