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Eligibility Determination Worker

Company: Texas Health & Human Services Commission
Location: Austin
Posted on: January 15, 2022

Job Description:

Performs routine consultative services and technical work to assist in the planning, development, implementation, and coordination of the daily operations and special projects of the Texas HIV Medication Program (THMP). Evaluates and applies operational processes based on program policies and procedures to determine eligibility for THMP clients. Trains other staff, governmental agencies, HIV service agencies, and the public on program eligibility criteria and application processing procedures.

Provides consultative and technical services to agency program staff, other governmental agencies, community/professional organizations and the public to help coordinate and improve client access to the program and to promote client adherence to physician prescribed medication regimens. Contributes to the development of program literature and educational material. Develops, implements and maintains data collection and analysis programs using available software applications. Assists the Program Manager with planning, assigning and evaluating work duties performed by others. Work is performed under the supervision of the Program Manager with moderate supervision and limited latitude for the use of initiative and independent judgment.

Essential Job Functions:

(10%) Provides support to the Regional Coordinator and collaborates with other program staff in the development of eligibility guidelines and screening processes (including applications, forms and instructions). Assists in ensuring eligibility guidelines and screening processes maintain compliance with Ryan White payer of last resort requirements and coordinate client needs with other available community resources and services. Assists in reviewing policies related to assigned region at least annually and preparing justifications for changes identified as necessary.

(30%) Assists with eligibility determinations for new, recertification, and self-attestation applications for medication assistance through the Texas HIV Medication Program in the assigned region. Applications include those for the AIDS Drug Assistance Program (ADAP), State Pharmacy Assistance Program (SPAP), and other special or pilot programs administered by the THMP. These applications have been reviewed, had demographic information entered into the Texas HIV Medication Program (THMP) database, and had verification information entered and attached to the application by the Public Health and Prevention Specialist II. Reviews proof of HIV positivity, financial eligibility, Texas residency, and insurance status, including both documentation provided by the applicant and verification information provided with the application to determine if the application is approved or incomplete.

(15%) Assists in determining eligibility denials for applicants who do not meet program criteria by providing an initial determination. All eligibility denials will receive a secondary review by the Regional Coordinator for the Eligibility Determination Worker's assigned region, who makes the final eligibility determination. Additionally, will transfer any requests for special exceptions, challenging situations and appeals to the Regional Coordinator. Other THMP Coordinators and Team Leads are available for these functions in the Regional Coordinator's absence.

10%. Composes a letter of determination the applicant and the Community ADAP Enrollment Worker who assisted with the application with the letter of denial, approval, or incomplete application. Denial letters will include the reason for the denial and information on other available services for HIV Medications and Incomplete Application denial letters will include information on what information was missing and how to reapply. Approval letters will be sent to the applicant, Community ADAP Enrollment Worker, and the assigned pharmacy.

(10%) Inputs all eligibility information into the THMP database, including updating demographic information previously entered into the system, noting documentation and relevant details of how eligibility determination was made, and selecting type of eligibility determination.

(10%) Compiles and evaluates statistical data used to develop THMP eligibility projections. Provides weekly statistical information to the THMP Manager, including productivity counts and data for quality improvement reviews. Assists with preparing administrative reports for THMP's Advisory Committee. Reviews and prepares research findings relative to project development. Develops, implements, and maintains data collection and analysis programs using available software applications. Assists in THMP Quality Management committee and quality management activities. Assists in program planning, development, implementation and evaluation.

(10%) Serves as a liaison with local ADAP Enrollment Workers who assist with application completion in the region, assisting with explaining the application process and requirements of the THMP. Performs THMP outreach efforts, assisting in planning and delivering training and workshops specific to the eligibility process for the assigned region. Assists with cross training THMP staff.

(5%) Marginal function - relevant and timely projects as assigned by the Program Manager. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency's obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.


Knowledge Skills Abilities:

Knowledge of current social, economic, and public health issues related to HIV/AIDS; public health laws and regulations; of educational techniques and procedures; and of medical terminology and medications commonly used in the treatment of HIV/AIDS and STDs.

Skill in performing applicant eligibility determination using identified screening criteria; in composing, organizing, proofreading, and editing requisitions, reports, and correspondence for accuracy and clarity; in instructing others; and in using personal computers for data entry, running reports, and developing correspondence using Excel and Word.

Ability to train others; to interpret Public Health laws and regulations; to analyze and assess public health needs; to perform data entry with speed and accuracy; to effectively communicate verbally and in writing; to develop, implement, and evaluate policies and procedures; to understand and adhere to applicable laws and rules regarding confidential information; to plan, organize and coordinate multiple projects while meeting strict deadlines under minimal supervision; to handle and process materials that are highly time-sensitive and that require rapid processing; and to verify client eligibility using third-party verification processes.

Registration or Licensure Requirements:

Initial Selection Criteria:

Graduation from an accredited four-year college or university with major course work in social work, public health or health care administration. Experience and education may be substituted for one another. Additional Information:

Req.# 508038

Must be legally authorized to work in the U.S. without sponsorship. MOS Code:

OS; YN; YNS; 611X; 641X; 712X; OSS; 8U000, 16GX; 60G0; 86M0; 86P0; 88A0

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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Keywords: Texas Health & Human Services Commission, Austin , Eligibility Determination Worker, Other , Austin, Texas

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