Medical/Social Services Consultant II

Delaware LLC; Delaware; On-site; USD 65,000 - 90,000; Full time

Job summary

Department of Health and Social Services (DHSS) in Delaware is seeking a Medical/Social Services Consultant II to perform advanced quality control reviews under MEQC, focusing on Medicaid and Medical Assistance cases. You will assess eligibility, analyze data, and help ensure compliance with state and federal requirements.

The role requires a Bachelor’s degree plus multi-year experience in case management, program review, and policy interpretation, with opportunities to influence program

Qualifications

• Bachelor's degree or higher in Health, Behavioral or Social Science or related field.
• Two years' experience in case management including assessing, planning, developing, implementing, monitoring, and evaluating options and services.
• Two years' experience in making recommendations as part of a client's service plan such as clinical treatment, counseling, or determining eligibility for health or human services/benefits.
• Two years' experience in client healthcare resource coordination and support.
• Six months' experience interpreting laws, rules, regulations, standards, policies, and procedures.
• Six months' experience in narrative report writing.

Responsibilities

• Manages cases over the continuum of a healthcare delivery system for clients with complex, chronic, and specialized medical conditions.
• Collaborates with health care providers, services, programs, and insurance entities to develop tailored service plans and interventions.
• Navigates and coordinates pre-authorizations and referrals between clients, providers, and insurance programs.
• Schedules and attends multidisciplinary evaluations and assessments; supports discharge and transition planning.
• Responds to casework inquiries and investigates complaints, assessing services or eligibility against entitlements or contracts.
• Provides outreach and education to program staff and stakeholders to promote community health and wellness.
• Maintains data sets for reporting and program planning and coordinates funding sources for special eligibility.

Skills

Case management experience

Healthcare resource coordination

Policy interpretation

Narrative reporting

Education

Bachelor's degree or higher in Health, Behavioral or Social Science or related field

Job description

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.

Introduction

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 https://dhss.delaware.gov/dhss/ today!

Summary Statement

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.

Essential Functions

• 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 perform more advanced work under minimal supervision. Employees at this level perform program and quality review work and may also assist in the evaluation and planning of existing programs to better target Social Determinants of Health factors for underserved or high‑risk populations.

• Receives minimal supervision from a technical or administrative supervisor; the supervisor defines objectives, priorities, and deadlines and assists the employee with unusual situations.
• Independently provides quality assessments such as oversight and review of eligibility determination work, chart audits, and/or formal examination of service delivery obligated under regulatory entities, waivers, or contracts. Documents and prepares comprehensive reports of found deficiencies and recommends correction plans to remain in compliance.
• Analyzes service metrics against existing policies/ services to identify barriers to care or services, drafting recommendations for policy changes that promote wellness and equitable access to health services.
• Identifies trends in client needs and contributes to planning sessions on program development and the implementation of new services or protocols.
• Leads the planning and coordination of community facing events such as testing clinics, fairs, school outreach, programs and other group events that support population health goals, targeting positive impacts on the Social Determinants of Health (SDOH) for underserved or high‑risk populations.
• May supervise a small staff of lower‑level case workers and/or administrative support staff. Supervision includes two or more merit full‑time positions. The elements of supervision include performing the following on a regular and continuing basis: planning, assigning, reviewing, evaluating, coaching, training, disciplining, and recommending hire, termination, and promotion.
• May serve on boards or special committees as a subject matter expert or advocate.

Job Requirements

Applicants must have education, training and/or experience demonstrating competence in each of the following areas:

• Possession of a Bachelors degree or higher in Health, Behavioral or Social Science or related field.
• Two years' experience in case management such as assessing, planning, developing, implementing, monitoring, and evaluating options and services to meet an individual's human service needs.
• Two years' experience in making recommendations as part of a client's service plan such as clinical treatment, counseling, or determining eligibility for health or human services/benefits.
• Two years' experience in client healthcare resource coordination and support.
• Six months experience in interpreting laws, rules, regulations, standards, policies, and procedures.
• Six months experience in narrative report writing.

Conditions of Hire

All new hires are required to report to the Statewide New Employee Orientation (SNEO) on their first day of employment. Sessions are held at designated locations in Kent or New Castle County. Applicants must be legally authorized to work in the United States. The State of Delaware participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. DHSS does not provide employment-based sponsorship.

Benefits

To learn more about the comprehensive benefit package please visit our website at https://dhr.delaware.gov/benefits/

Accommodations

Accommodations are available for applicants with disabilities in all phases of the application and employment process. Individuals who use TDD may request auxiliary aid or service by calling [phone] or by visiting delawarerelay.com. If you need assistance with an accommodation under the Americans with Disabilities Act (ADA) or general applicant support, you may call [phone] or email [e-mail].

The State of Delaware is an Equal Opportunity employer and values a diverse workforce. We strongly encourage and seek out a workforce representative of Delaware including race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression.