Program Support Specialist

Justification for AdditionalStaffing

Summary

DMAHS requests temporary staffingenhancements for the Fair Hearing Unit (FHU) to meet federal Fair Hearingrequirements and fulfill obligations under the Centers for Medicare &Medicaid Services (CMS) Fair Hearing Compliance Plan. Current staffing is insufficientto manage ongoing workloads, resolve accumulated cases, support requiredtechnology modernization, or meet federally mandated timelines. Additionalresources are also needed to develop an informal resolution process andidentify cases that can be resolved prior to transmittal to the Office ofAdministrative Law (OAL). These needs are intensified by anticipated increasesin Fair Hearings resulting from H.R. 1 changes in citizen eligibility,expanded work requirements, and higher renewal volume.

Federal Compliance Drivers

In its November 26, 2024, letter,CMS identified the State's Fair Hearing delays as a major compliance concernand directed New Jersey to restore timely processing before the expiration offederal flexibilities on June 30, 2026. CMS emphasized the following:

Finaladministrative action on Fair Hearing requests must occur within 90 days(42 CFR 431.244).

DHSmust maintain effective oversight as the single State Medicaid agency(42 CFR 431.10).

Ongoingdelays may result in corrective action or financial penalties.

The CMS Compliance Plan alsorequires measurable improvements in case processing timeliness, accuracy ofcase closure and benefit updates, and reliable data reporting, which are areas that depend on both staffing capacity and upgraded technology.

Operational Need

1. Case Processing, Transmittals,and Informal Resolution

The CMS Compliance Plan requirestimely receipt, triage, and transmittal of all Fair Hearing requests. Currentstaffing levels cannot keep pace with sustained case volume, now furtherincreased by new legislation, work requirements, and rising renewal activity.Additional staffing is needed to process requests in real time, conductenhanced case triage, and identify cases appropriate for informal resolutionbefore transmittal to the OAL. Strengthening these front-end functionsdirectly supports CMS's expectations for timely case movement, reducesunnecessary hearings, and improves the overall experience for beneficiaries.

2. Case Closure, Scanning, andVerification

The Compliance Plan emphasizes theneed for timely and accurate closure of resolved or withdrawn cases, including confirmation of benefit status. These activities require consistent scanning,document processing, system updates, and coordination with counties, ManagedCare Organizations (MCOs), and the Health Benefits Coordinator. Increasedstaffing is needed to ensure these functions occur reliably, prevent recurringdelays, and maintain the accuracy CMS requires for oversight and reporting.

3. Data Reconciliation and Reporting

CMS requires accurate, reconcileddata across DMAHS, OAL, counties, MCOs, and other partners. Increasing hearingvolume and historical inconsistencies require dedicated staff to managereconciliation, validate records, and maintain required reporting tools.

4. Technology Modernization andSystem Improvements

The CMS Compliance Plan alsoidentifies significant modernization and workflow improvements that must besupported to achieve and sustain compliance. This includes strengthening theFair Hearing tracking system to support real-time updates and reporting,developing system functionality to support informal resolution and enhancedtriage, improving electronic integration and data exchange with the OAL,standardizing and automating member notices and workflow steps to reduce manualprocessing, and expanding dashboards and analytics tools needed for compliancemonitoring. Developing and implementing these improvements requires dedicatedstaffing to support business requirements, system design, testing, datavalidation, and rollout while maintaining day-to-day operational functions.

Primary duties include:

Analyzeincoming mail, faxes, correspondence, and appeal requests to determinecontested issues.

Inputand maintain case information in the LRL Oracle database and other agencyinformation systems.

Review,process, and manage Fair Hearing cases from receipt through final disposition.

Prepare,organize, and transmit Fair Hearing case files to the Office of AdministrativeLaw (OAL) for scheduling.

Trackcontested cases throughout the appeals lifecycle, monitor case status, andensure timely processing, resolution, and closure.

Monitorterminations and continuation of benefits by coordinating with the MCOCoordinator Unit, including requests to add or remove the appropriate"19" code based on case status.

Coordinateinformal resolution efforts by communicating with County Welfare Agencies(CWAs), Managed Care Organizations (MCOs), OCCO, providers, petitioners,representatives, and other eligibility-determining agencies regardingsettlements, withdrawals, resolutions, and requests for additional information.

Return matters to CWAs for re-review when appropriate, including failure-to-provide termination cases.

Respond to inquiries regarding program activities and Fair Hearing requirements andrefer complex matters to senior staff.

Prepareand maintain transmittal documents, legal correspondence, case summaries,charts, reports, tables, and other materials supporting program operations.

Generatemonthly reports detailing outstanding, accepted, declined, resolved, andpending Fair Hearing requests.

Researchapplicable federal and State laws, regulations, policies, and proceduressupporting the Fair Hearing process.

Scan,organize, maintain, and retain electronic and hard-copy case files, ensuringall supporting documentation and legal records comply with agency recordkeepingrequirements.

Monitor and reconcile pending appeals, identify cases requiring additional documentation or agency action, and conduct follow-up with internal and external stake holders to ensure records remain accurate and complete.

Coordinateand document legal processes necessary to facilitate the Fair Hearing appeals process efficiently and accurately.

Establishprocessing timelines for appeal requests in coordination with the legal team.

Preparedetailed reports regarding case status, workload, and program activity.

Utilizevarious electronic and manual information systems used by the agency to supportFair Hearing operations.

Ensurecompliance with federal Medicaid requirements, including requirementsassociated with the Public Health Emergency (PHE) Unwinding and ongoing CMSFair Hearing mandates.

Minimum Requirements

Abilityto assemble data and prepare accurate and informative reports containingfindings, conclusions, and recommendations.

Abilityto review, interpret, and evaluate data and other information.

Abilityto read and interpret laws, regulations, standards, policies, and proceduresand apply them appropriately.

Abilityto research legal materials, including court decisions, precedents, legalopinions, and citations, and evaluate documents for compliance with New JerseyState and federal laws and regulations.

Abilityto recognize, analyze, and resolve routine program issues.

Abilityto maintain accurate records and files.

Abilityto prepare technically sound reports.

Abilityto work cooperatively with supervisors, coworkers, and external stakeholders.

Stronganalytical and problem-solving skills.

Proficiencyin Microsoft Office Suite.

Dataentry and customer service experience.

Abilityto read, write, speak, understand, and communicate effectively in English.