Nurse Fair Hearings Officer

Hearings Officer V

Performs advanced legal and technical work involving administrative hearings for complex Medicaid programs that may involve general counsel, opposing attorneys, disability rights, high dollar amounts, and sensitive cases administered by the Health and Human Services Commission (HHSC) and other state agencies contracting with HHSC. Work involves overseeing and presiding over a high volume of Medicaid fair hearings on matters requiring interpretation and application of a diverse array of state and federal laws and regulations. Hearings Officers ensure adverse determinations comply with laws and program policies. Hearings Officers must understand the appropriate role and expected conduct of an administrative judge and the duties required to prepare for and conduct a fair hearing. Hearings Officers must effectively communicate with appellants and their representatives as well as state employees, and service providers; arrive at the appropriate facts of a case; and render an impartial decision.

Leads and guides less tenured Hearings Officers. Performs quality assurance reviews of decisions for other Hearings Officers for compliance with federal and state legislative requirements and appropriate policy interpretation. Identifies training needs and provides training to staff. Manages area staff in the absence of the area manager. Attends monthly management meetings with the Director. Monitors staff by pulling reports in TIERS. Assists the area Manager with the hiring process. Works under minimal supervision with extensive latitude for the use of initiative and independent judgment.

Presides over Medicaid fair hearings for more complex, high profile, high dollar durable medical equipment, and sensitive cases for program areas including medical necessity for long term care, community care services, plan issues, nursing facility discharges, home health services, EPSDT services, dental cases, supplies and acute care medical procedures. (40%)

Admits, evaluates and interprets evidence including sworn testimony and appropriately applies law regarding procedural matters raised in hearings. Determines credibility and weighs evidence to determine if the agency has met its burden of proof regarding the medical eligibility of appellants. Responsible for rendering legally sufficient decisions for fair hearings, preparing findings of facts and conclusions of law, considering testimony and evidence, and writing orders establishing clear instructions to the agency. Requests policy and legal clarifications, if necessary. (40%)

Leads and guides Hearings Officers for compliance with federal and state legislative requirements and appropriate policy interpretation. Conducts quality assurance reviews of Hearings Officers’ decisions to ensure compliance. Identifies training needs and provides training to staff and assists with staff development. (10%)

Manages area staff in the absence of the area manager. Attends monthly management meetings with the Director. Monitors staff by pulling reports in TIERS. Assists the area Manager with the hiring process. (5%)

Tracks, monitors, plans, coordinates, and schedules activities on a complex level using TIERS, managing hearings docket to ensure deadlines and requirements are met. (5%)  

Knowledge, Skills, and Abilities (KSAs)

Knowledge of Medicaid policy, principles, and practices; and of Medicaid laws, regulations, and rules related to HHSC programs.

Skill in editing, writing, and analysis.

Ability to conduct sensitive Medicaid hearings, write clear and concise hearing decisions, conduct research, summarize findings, interpret and apply Medicaid law and policy, use legal reference materials, communicate effectively, and train others.  

Registrations, Licensure Requirments or Certifications

Must hold a clear and current Texas registered or vocational nursing license.

Initial Screening Criteria

Two years of experience as an LVN or RN required.

Experience in following instructions. 

Experience related to fair hearings is preferred. 

Additional Information

The Nursing Hearings Officer position will be located in one of the following locations: Lubbock, Texas; Houston, Texas; Abilene, Texas; Fort Worth, Texas; or San Antonio, Texas