Medical​/Social Services Consultant II

Make a Difference with DHSS Our mission at the Department of Health and Social Services (DHSS) is to improve the quality of life of Delaware citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. We prioritize personal and family independence by assisting individuals and families in a variety of life areas. We offer numerous career opportunities and are dedicated to attracting and retaining highly talented individuals who are ready to make a difference in their community today.

DHSS is a great place to kick-start your profession. For more information, please visit (Use the "Apply for this Job" box below). today!

Employees in this class perform federally mandated quality control reviews under the Medicaid Eligibility Quality Control (MEQC) Program to ensure accuracy and compliance with eligibility and benefits determinations. Primary work involves conducting third-party reviews of sampled statewide Medicaid and Medical Assistance cases. Employees apply in-depth knowledge of applicable program requirements, state and federal laws, rules, regulations, and quality control methods, as well as use discretion and independent judgment to perform reviews and assess eligibility accuracy.

Work includes researching, compiling, and analyzing data gathered through case sampling and review; obtaining and evaluating records and supporting documents; verifying household eligibility factors and benefits calculations; identifying errors and discrepancies; and determining whether cases were correctly processed and placed in the appropriate program. Cases must be reviewed within mandated time frames.

• Manages cases over the continuum of a healthcare delivery system for clients with complex, chronic, and specialized physiological medical conditions.
• Facilitates access to medical and social service resources across public, private, and community sectors.
• Collaborates with health care providers, services, programs, and insurance entities to develop tailored service plans and interventions.
• Integrates care and communication between stakeholders to ensure optimal health and social outcomes.
• Navigates and consults on the intersection of services, authorizations, and payments between the clients, providers, insurance programs and/or Managed Care Organizations.
• Works with providers and insurance entities to obtain pre-authorizations and referrals.
• Schedules and attends multidisciplinary evaluations and assessments.
• Facilitates and participates in discharge and transition planning.
• Formally responds to casework inquiries and investigates complaints, assessing services or eligibility against legal entitlements or contracts.
• Provides subject matter expertise through outreach and education to program staff, community members, providers, and other stakeholders through special community events or health education and preventative services.
• Advocates for community health and wellness.
• Maintains and tracks service, eligibility, and referral data sets, manages data for reporting and program planning. Coordinates and allocates funding sources for special program eligibility.
• May support emergency preparedness and response efforts during pandemics or natural disasters, and/or intervene in facilitating care for clients in health crisis.
• May provide home visits, and/or virtual appointments.
• Performs other related duties as required.

Medical/Social Services Consultant II This is advanced level medical/social services consultant work, with an emphasis on consultation and oversight of medically complex case management services. In addition to work performed at the Medical/Social Services Consultant I level, employees independently…