Job/Position DescriptionThe 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 document https://jobshrportal.hhsc.state.tx.us/ENG/CareerPortal/job_profile.cfm?szOrderID=615605 Copy the URL in the preceding sentence to an Internet Explorer browser to apply to the job directly through the Texas Health and Human Services Career Portal.