Complaint Resolution Specialist (AUSTIN, TX)

Job Description:
The Program Specialist II will support the Managed Care Compliance & Operations (MCCO) section by conducting in-depth analysis of complex inquiries and complaints and composing written responses to clients, agency staff, providers, advocates and Legislators; interpreting Texas Medicaid/CHIP and Medical Transportation rules, regulations, policies, and procedures and conducting research to resolve client issues and problems; and coordinating activities between clients and members, health care providers, contractors, advocates and other agencies. The Program Specialist also evaluates contractor adherence to contracts, policies, procedures, and guidelines; serving as a resource expert, creating and promoting awareness of available Medicaid/CHIP and Medical Transportation programs other government assistance and programs, and private sector resources. The Program Specialist identifies policy issues to be initiated, revised or deleted, and makes recommendations for a more effective program. 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. Receive, analyze, process and respond to inquiries and complaints pertaining to Medical Transportation and Medicaid Managed Care. Enter complaints and inquiries into the HEARTS tracking system in a timely manner. Communicate effective and professionally with the various Demand Response Transportation Service (DRTS) providers or Managed Care Organization and the HHSC staff through resolution. 2. On a regular basis participate in determining the effectives of operational and contractual compliance by utilizing a standard set of assessment tools and analyzing data. Promptly inform the Manager of significant compliance and quality improvement issues and provide recommendations for actions. Resolve contract performance and compliance issues by working collaboratively with the MCCO team to improve performance and contract compliance. Participate in the development and monitoring of corrective action plans, as appropriate. May also participate in the process to assess remedies or damages for failure to meet contract performance requirements. 3. Participate in functions related to special projects and investigations, including but not limited to the development of and revision of policy and procedures and desk manual. Respond to governmental, commercial, and advocacy organizations regarding issues within assigned timeframes. Manage or facilitate special research/issues projects as assigned within timeframes. 4. Establish and maintain effective working relationships and communications with HHSC staff, DRTS staff, MCO staff, and staff from other agencies and organizations. Provide timely responses to requests and inquiries. 5. Demonstrate commitment to the goals of the Medicaid/CHIP division, including showing initiative to take on new projects; being team-oriented; being committed to outstanding customer services; and being willing to think outside the box with a focus on promoting efficiencies and accountability. Apprise supervisor of work-related incidents or situations that could be problematic to staff, the department or the agency and apply proper judgment to assure action is appropriate.

Knowledge Skills Abilities:
Experience in Medical Transportation and Medicaid Managed Care, CHIP, DRTSs, MCOs, contracts, policies and/or procedures. Experience with complaint intake and resolution process. Analytical and organization skills and the ability to conduct investigations; gather, assemble, correlate, and analyze facts and data; and devise solutions to problems. Experience with state and federal laws, regulations and processes regarding Medical Transportation, Medicaid Managed Care and CHIP. Experience in using personal computer application software such as Microsoft Word, Business Objects, Excel, Power Point, HEART or other similar programs. Experience in written and oral communication Ability to research, evaluate complaint related information.

Registration or Licensure Requirements:
N/A

Initial Selection 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. 2. Experience in Medical Transportation, Medicaid, and CHIP managed care programs, policies, procedures, contracts and service delivery mechanisms/ model. 3. Experience with written and oral communication, including the ability to write technical information in an understandable format. 4. Experience in using a personal computer and application software such as Microsoft Word, Excel, Power Point, HEART or other similar programs.