Texas Health and Human Services Commission
Associate Medical Director of Appeals
Texas Health and Human Services Commission, Austin, Texas, us, 78716
Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage.
Functional Title:
Associate Medical Director of Appeals Job Title:
Physician II Agency:
Health & Human Services Comm Department:
Medical Directors Off 75-25 Posting Number:
9638 Closing Date:
10/31/2025 Posting Audience:
Internal and External Occupational Category:
Healthcare Practitioners and Technical Salary Group:
TEXAS-B-34 Salary Range:
$13,670.66 - $19,000.00 Pay Frequency:
Monthly Shift:
Day Additional Shift: Telework:
Eligible for Telework Travel:
Up to 10% Regular/Temporary:
Regular Full Time/Part Time:
Full time FLSA Exempt/Non-Exempt:
Exempt Facility Location: Job Location City:
AUSTIN Job Location Address:
4601 W GUADALUPE ST Other Locations: MOS Codes:
210X,42EX,42FX,42NX,44AX,44BX,44DX,44EX,44FX,44GX,44HX,44JX,44KX,44MX,44NX,44OX,44RX,44SX,44TX,44UX 44YX,44ZX,45AX,45BX,45EX,45GX,45NX,45PX,45SX,45UX,48AX,48GX,48OX,48RX,48VX,60A,60B,60C,60D,60H,60J 60K,60L,60N,60P,60S,60T,60V,61E,61F,61G,61H,61J,61K,61L,61M,61N,61P,61Q,61R,61U,61W,61Z,62A,62B,62Z 67F,67G,SEI12
Brief Job Description:
The Associate Medical Director of Appeals will use medical training and experience to conduct activities and lead processes in several areas of relevance to the Medicaid and CHIP Services Division (MCS) within the Office of Medical Director (OMD). MCS is driven by its mission to deliver quality, cost-effective services to Texans. Among other functions, OMD provides clinical consultation and guidance to other areas within MCS, throughout the Agency, and to external stakeholder organizations. It works to provide a clinical vision for improving the health of Texans by aligning MCS programs with state public and population health priorities.
Primary duties will relate to completion of appeal reviews of claims billed to Medicaid that have been denied by any of several review entities. Medical records and other submitted information is reviewed to determine medical necessity for hospital admissions, the appropriateness of procedures billed under an inpatient status, and the accuracy and appropriateness of billed diagnoses and procedures. This work also involves interaction with members of a team performing various aspects of the appeal review process and providing feedback and oversight of certain team members. Effective written and oral communications with stakeholders in the appeal process, including staff and billing providers, will be essential. The physician will have or will develop a deep understanding of the billing process, diagnosis related groups, inpatient versus outpatient procedures, observation versus inpatient status, Medicaid policies, basic managed care organization operation, Texas Medicaid goals, and related laws and rules. The physician may provide oversight for and communicate with independent review organizations performing portions of the appeal review work.
The physician in this position will also be a part of the broad MCS team and will provide clinical consultation and support for a variety of other departments. The physician will provide medical consultation and direction for benefits design and development and for all medical services in Medicaid and CHIP. This may include attending department meetings, reviewing policy documents, or responding to inquiries from external stakeholders.
The physician will provide guidance in completing major projects as directed through the Chief Medical Director and help provide cross-coverage for other MCS medical directors and the Chief Medical Director. Other duties may be assigned and required.
The physician may be tasked to interface and provide support for advisory committees or other groups external to HHSC. This may involve public speaking to such groups, helping with development of policy statements or reports, and developing training materials.
The physician in this position will not provide direct medical care.
The candidate must be able to work under minimal direction with extensive latitude for the use of initiative and independent judgment yet must be able to accept direction and work as a team member.
The ideal candidate thrives in an environment that emphasizes: teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.
This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
Approximately 10% travel may be required.
Essential Job Functions (EJFs):
(60%) Performs and supervises others in performing appeal reviews by reviewing medical records and other submitted documentation.
(15%) Performs review of assessments and associated documentation for determination of waiver eligibility and medical necessity.
(10%) Provides medical consultation and direction for other MCS departments, including those developing benefits policy.
(5%) Participates in intra-agency- and interagency staff meetings and committees related to Medicaid and CHIP issues.
(5%) Acts as liaison with and presents to selected governmental agencies and professional medical and lay groups interested in Medicaid and CHIP issues.
(5%) Conducts other duties as assigned.
Knowledge, Skills and Abilities (KSAs):
Knowledge of medical methods, procedures, and trends of the principles and practices in the development.
Knowledge in implementation and documentation of individualized care and treatment plans.
Knowledge of disease management and risk analysis.
Knowledge of the Medicaid Program and Children's Health Insurance Program to include Medicaid waiver programs.
Knowledge of and expertise in the clinical practice guidelines development process.
Knowledgeable of the principles of leadership and how to effectively interact with various leadership styles.
Ability to plan, assign, and evaluate the work of others.
Ability to work collaboratively and build strong relationships with key staff and stakeholders.
Ability to interact effectively and professionally with persons from diverse cultural, socioeconomic, educational, racial, ethnic, and professional backgrounds.
Ability to understand and effectively interpret agency and program rules, policies, and procedures.
Ability to perform policy and medical research to include critical appraisal of scientific literature.
Ability to communicate effectively orally and in writing. •Ability to work independently with minimal supervision.
Skill in the care of and treatment of patients to include use of diagnostic and treatment tools and equipment.
Skill in problem identification, analysis, and resolution.
Skill in the use of computer software, specifically Windows, Microsoft Outlook, Word, Excel, and Power Point.
Registrations, Licensure Requirements or Certifications:
Medical degree from a U.S. accredited medical college or university (either allopathic or osteopathic) or a foreign medical degree determined to be equivalent by an acceptable education evaluator.
Candidate must be board certified in a specialty/subspecialty as recognized by the American Board of Medical Specialties.
Initial Screening Criteria:
Completion of a residency program accredited by the Accreditation Council for Graduate Medical Education.
Candidate must be licensed as a Medical Doctor by the state of Texas and be in good standing.
At least five years of experience as a practicing physician in a predominantly clinical setting (not including residency training).
At least two years of experience with one or more of the following: quality assurance, quality improvement, utilization review, utilization management, and/or medical appeals processes.
Additional Information:
N/A
Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.
Active Duty, Military, Reservists, Guardsmen, and Veterans :
Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor's Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.
ADA Accommodations:
In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS 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.
Pre-Employment Checks and Work Eligibility:
Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.
HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form
Telework Disclaimer:
This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
Functional Title:
Associate Medical Director of Appeals Job Title:
Physician II Agency:
Health & Human Services Comm Department:
Medical Directors Off 75-25 Posting Number:
9638 Closing Date:
10/31/2025 Posting Audience:
Internal and External Occupational Category:
Healthcare Practitioners and Technical Salary Group:
TEXAS-B-34 Salary Range:
$13,670.66 - $19,000.00 Pay Frequency:
Monthly Shift:
Day Additional Shift: Telework:
Eligible for Telework Travel:
Up to 10% Regular/Temporary:
Regular Full Time/Part Time:
Full time FLSA Exempt/Non-Exempt:
Exempt Facility Location: Job Location City:
AUSTIN Job Location Address:
4601 W GUADALUPE ST Other Locations: MOS Codes:
210X,42EX,42FX,42NX,44AX,44BX,44DX,44EX,44FX,44GX,44HX,44JX,44KX,44MX,44NX,44OX,44RX,44SX,44TX,44UX 44YX,44ZX,45AX,45BX,45EX,45GX,45NX,45PX,45SX,45UX,48AX,48GX,48OX,48RX,48VX,60A,60B,60C,60D,60H,60J 60K,60L,60N,60P,60S,60T,60V,61E,61F,61G,61H,61J,61K,61L,61M,61N,61P,61Q,61R,61U,61W,61Z,62A,62B,62Z 67F,67G,SEI12
Brief Job Description:
The Associate Medical Director of Appeals will use medical training and experience to conduct activities and lead processes in several areas of relevance to the Medicaid and CHIP Services Division (MCS) within the Office of Medical Director (OMD). MCS is driven by its mission to deliver quality, cost-effective services to Texans. Among other functions, OMD provides clinical consultation and guidance to other areas within MCS, throughout the Agency, and to external stakeholder organizations. It works to provide a clinical vision for improving the health of Texans by aligning MCS programs with state public and population health priorities.
Primary duties will relate to completion of appeal reviews of claims billed to Medicaid that have been denied by any of several review entities. Medical records and other submitted information is reviewed to determine medical necessity for hospital admissions, the appropriateness of procedures billed under an inpatient status, and the accuracy and appropriateness of billed diagnoses and procedures. This work also involves interaction with members of a team performing various aspects of the appeal review process and providing feedback and oversight of certain team members. Effective written and oral communications with stakeholders in the appeal process, including staff and billing providers, will be essential. The physician will have or will develop a deep understanding of the billing process, diagnosis related groups, inpatient versus outpatient procedures, observation versus inpatient status, Medicaid policies, basic managed care organization operation, Texas Medicaid goals, and related laws and rules. The physician may provide oversight for and communicate with independent review organizations performing portions of the appeal review work.
The physician in this position will also be a part of the broad MCS team and will provide clinical consultation and support for a variety of other departments. The physician will provide medical consultation and direction for benefits design and development and for all medical services in Medicaid and CHIP. This may include attending department meetings, reviewing policy documents, or responding to inquiries from external stakeholders.
The physician will provide guidance in completing major projects as directed through the Chief Medical Director and help provide cross-coverage for other MCS medical directors and the Chief Medical Director. Other duties may be assigned and required.
The physician may be tasked to interface and provide support for advisory committees or other groups external to HHSC. This may involve public speaking to such groups, helping with development of policy statements or reports, and developing training materials.
The physician in this position will not provide direct medical care.
The candidate must be able to work under minimal direction with extensive latitude for the use of initiative and independent judgment yet must be able to accept direction and work as a team member.
The ideal candidate thrives in an environment that emphasizes: teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.
This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
Approximately 10% travel may be required.
Essential Job Functions (EJFs):
(60%) Performs and supervises others in performing appeal reviews by reviewing medical records and other submitted documentation.
(15%) Performs review of assessments and associated documentation for determination of waiver eligibility and medical necessity.
(10%) Provides medical consultation and direction for other MCS departments, including those developing benefits policy.
(5%) Participates in intra-agency- and interagency staff meetings and committees related to Medicaid and CHIP issues.
(5%) Acts as liaison with and presents to selected governmental agencies and professional medical and lay groups interested in Medicaid and CHIP issues.
(5%) Conducts other duties as assigned.
Knowledge, Skills and Abilities (KSAs):
Knowledge of medical methods, procedures, and trends of the principles and practices in the development.
Knowledge in implementation and documentation of individualized care and treatment plans.
Knowledge of disease management and risk analysis.
Knowledge of the Medicaid Program and Children's Health Insurance Program to include Medicaid waiver programs.
Knowledge of and expertise in the clinical practice guidelines development process.
Knowledgeable of the principles of leadership and how to effectively interact with various leadership styles.
Ability to plan, assign, and evaluate the work of others.
Ability to work collaboratively and build strong relationships with key staff and stakeholders.
Ability to interact effectively and professionally with persons from diverse cultural, socioeconomic, educational, racial, ethnic, and professional backgrounds.
Ability to understand and effectively interpret agency and program rules, policies, and procedures.
Ability to perform policy and medical research to include critical appraisal of scientific literature.
Ability to communicate effectively orally and in writing. •Ability to work independently with minimal supervision.
Skill in the care of and treatment of patients to include use of diagnostic and treatment tools and equipment.
Skill in problem identification, analysis, and resolution.
Skill in the use of computer software, specifically Windows, Microsoft Outlook, Word, Excel, and Power Point.
Registrations, Licensure Requirements or Certifications:
Medical degree from a U.S. accredited medical college or university (either allopathic or osteopathic) or a foreign medical degree determined to be equivalent by an acceptable education evaluator.
Candidate must be board certified in a specialty/subspecialty as recognized by the American Board of Medical Specialties.
Initial Screening Criteria:
Completion of a residency program accredited by the Accreditation Council for Graduate Medical Education.
Candidate must be licensed as a Medical Doctor by the state of Texas and be in good standing.
At least five years of experience as a practicing physician in a predominantly clinical setting (not including residency training).
At least two years of experience with one or more of the following: quality assurance, quality improvement, utilization review, utilization management, and/or medical appeals processes.
Additional Information:
N/A
Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.
Active Duty, Military, Reservists, Guardsmen, and Veterans :
Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor's Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.
ADA Accommodations:
In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS 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.
Pre-Employment Checks and Work Eligibility:
Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.
HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form
Telework Disclaimer:
This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.