Claims Examiner III

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: Claims Examiner III Job Title: Claims Examiner III Agency: Health & Human Services Comm Department: MEPD Disability Det EOAPD Posting Number: 18206 Closing Date: 07/06/2026 Posting Audience: Internal and External Occupational Category: Community and Social Services Salary Range: $3,793.41- $5,921.25 Pay Frequency: Monthly Salary Group: TEXAS-B-18 Shift: Day Additional Shift: Telework: Eligible for Telework Travel: Up to 40% Regular/Temporary: Regular Full Time/Part Time: Full time FLSA Exempt/Non-Exempt: Nonexempt Facility Location: Job Location City: BRYAN Job Location Address: 3000 E VILLA MARIA Other Locations: Brenham; Austin; Killeen; Round Rock; Waco MOS Codes: No military equivalent Brief Job Description: Are you a highly motivated, compassionate and dedicated individual looking for a rewarding career assisting the most vulnerable citizens of Texas in need of food, medical care, cash assistance and other social services? If so, the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) division is looking for individuals who want to join an exciting, dynamic team working in a high-performing and innovative environment. AES provides an integrated and streamlined approach to connect individuals to services and supports that: reduce institutionalization, allow individuals to remain in their communities, and promote economic and personal self-sufficiency. AES is built upon its' core values of respect, ownership, collaboration, and integrity with a goal of delivering best-in-class customer service to clients and stakeholders. Our staff are well organized, able to multi-task, possess the ability to learn policy regulations, able to thrive in a challenging, fast-paced, and evolving environment, have good communication skills, a positive attitude, strong work-ethic and a desire to help others. If you also possess these skills, then we are looking for you. We want you to join our team! This position is responsible for implementation of the disability determination policies/procedures. This position is responsible for reviewing medical and social history information to determine applicant's ability to perform substantial gainful activity under the Disability Determination application and review process for cases. This position consults with staff physician, regional staff, medical providers, and legislators. This position interprets program policies and procedures, prepares appeal summaries and participates in Fair Hearings for appeal cases. This position works closely with the Disability Determination Manager to develop and maintain uniformity of disability determination processes and decisions. Assists Manager in conducting presentations and training of disability determination policy and procedures to agency staff and others as requested. Assists Manager in coordination of disability determination policy/procedure changes with appropriate policy staff. Provides technical supervision to clerical support staff. This position may require up to 40% of travel. Essential Job Functions (EJFs): Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Provides interpretation and application of federal disability requirements and procedures in the disability determination process for Medicaid applicants. Receives social and medical records from the Medicaid Eligibility Specialist and may have direct contact with Medicaid applicants occasionally. The position interprets the medical and social records and applies the "Federal SSI Listings of Impairments" using the five step "Sequential Evaluation Process", to determine if the applicants meet federal requirements for disability eligibility. Errors of interpretations could result in loss of benefits or harm to the applicant's health. Errors also could possibly result in federal sanctions and loss of Medicaid funds. Assists in the development of policies, procedures, rules, regulations or standards on disability determination cases. Provides complex technical assistance to regional staff, medical providers, legislators, and general public on policies, procedures, rules, regulations, standards or requirements in disability cases for Medicaid eligible applicants. Assists in the development and presentation of training on disability determination policy and procedures. Testifies as a technical authority and represents Disability Determination by participation in Appeal Hearings. May conduct program analyses and research to assess and formulate changes in processes or procedures. Knowledge, Skills and Abilities (KSAs): Knowledge of: Health and Human Services Programs services and procedures. Medical reporting format and terminology. Skill in: Analysis Working independently Ability to: Exercise tact, diplomacy and confidentiality in communication with others. Read and interpret medical reports in terms of residual functional capacity. Function as a member of a medical review team. Learn and apply state/federal disability policies and procedures. Pinpoint obscure detail. Work under pressure while maintaining effective and accurate performance. Communicate effectively both orally and in writing. Registrations, Licensure Requirements or Certifications: N/A Initial Screening Criteria: High School diploma or GED equivalent is required. Sixty (60) semester hours from an accredited college or university is required. Two (2) years of customer service experience may be substituted for required education. Experience working in a professional customer service environment. Two (2) years' experience as an Eligibility Advisor - MES (Medicaid Eligibility Specialist). Experience (within the last two (2) years) in Medicaid or Medicaid for the Elderly and People with Disabilities (MEPD) policy and procedures. One (1) year experience as an Eligibility Advisor III - MES (Medicaid Eligibility Specialist) or higher, preferred. Texas Integrated Eligibility Redesign System (TIERS) and Eligibility Workload Management System (EWMS) experience is preferred. Experience in medical reporting and terminology, preferred. Experience analyzing complex state and federal law and regulations, preferred. Experience analyzing operations and problems and preparing reports of findings and recommendations is preferred. Experience using computer software such as Microsoft Word, Excel, and Outlook. Application indicates the willingness to work beyond normal work hours of 8:00 AM - 5:00 PM. Application indicates the willingness to travel. Additional Information: This position can be housed anywhere in Region 07, where space is available. Access and Eligibility Services Field Office normal hours of operation are Monday-Friday 8:00am to 5:00pm. Employees may be required to work overtime, as required by management, outside of normal hours of operation, which may include weekends. Applicants selected for hire will be required to pass a fingerprint criminal history background check. Applicants may not have a history of substantiated fraudulent activity against HHSC or any program it administers. Applicants who have a non-fraud overpayment with an outstanding balance must agree to repay the overpayment balance as a condition of employment. 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 View phone number on click.appcast.io. 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.