JOB SUMMARY

Under the direction of VP of Medical Affairs and Sr. Manager of Appeals and Grievances this position includes the planning, coordination, organization and direction of the Star Plus LTSS appeal and State Fair Hearing and EMR/IRO activities of Community Health Choice while abiding by all regulatory requirements as outlined by HHSC in regard to LTSS services. Supervisor of State Fair Hearing Appeals and Grievance is responsible for overseeing and managing the State Fair Hearing Process, which entails reviewing the EMR SFH request in relation to Community Health Choice, government program or services. Overseeing the LTSS EMR SFH process from start to finish. Attend any mandated HHSC Supervisor of State Fair Hearing Appeals and Grievance will attend any mandated HHSC trainings.

JOB SPECIFICATIONS

Essential Functions

• Supervises, trains, and evaluates subordinate staff (Star Plus State Fair Hearing/EMR Coordinator); Attends administrative hearings representing Community along with other professional staff of the organization such as Star Plus Care Coordinators.
• Request access to the online TIERS HHSC portal and submit LTSS FH requests when requested and maintain access.
• Reviews requests for fair hearings from members; Creating EMR SFH cases in HHSC portal and coordinating hearing functions with professional staff of the organization in preparation for the fair hearing.
• Knowledgeable with interpreting relevant laws, regulations, guidelines, and policies to apply to cases during a state fair hearing. Reviews case files to determine whether agency actions are in conformance with regulations; Research applicable laws and regulations and contacts the State for interpretation on questionable issues.
• Ensuring accurate and thorough documentation of EMR SFH hearings, decisions, and related records. Assisting, reviewing, and creating evidence packets to send to appellants before the hearing for, monitor process collaborate with Service Coordinators to defend their assessments when PAS, PS, etc. are an issue or are the substance of SFH/EMR.
• Communicating with appeal/grievance staff, Star Plus Care Coordinators, Care Management, medical directors, appellants, legal representatives, and government agencies on issues related to the hearings, obtaining updates and additional information.
• Preparing reports on outcomes of hearings for quality improvement purposes.
• Administrative Duties: Consults with management and staff, as needed, to gather additional details; if corrective action is necessary, notifies the appropriate supervisor.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: High School Diploma or Equivalent required. Associate of bachelors degree in healthcare administration
• Work Experience (Years and Area): 3 years of experience and knowledge regarding Star+ Plus benefits for STARPLUS, the STAR+PLUS Handbook, the UMCC, and UMCM. 5 or more of years experienced in a MCO for STAR PLUS
• Management Experience (Years and Area): At least 2 Years experience in STAR PLUS Managed Care Organization, 5 years or more Experience in a MCO for STAR PLUS
• Software Proficiencies:Microsoft Word, Excel Spreadsheet, TEAMS,