Acute Care Utilization Review (ACUR) Clinical Lead

TX-HHSC-DSHS-DFPS • Austin, TX

3d • Hybrid

About The Position

Under the general supervision of the Director of ACUR, the ACUR Clinical Lead is responsible for highly advanced (senior level) activities related to supporting and assisting the ACUR Clinical Managers with oversight of clinical reviews of Medicaid Managed Care Organizations. This position requires a keen understanding of ACUR functions; has a strong clinical background; possesses critical thinking and organizational skills in ensuring positive outcomes for the ACUR’s oversight activities; confidence in independent decision-making.
This position has extensive latitude for use of initiative and independent clinical judgment in the oversight of the ACUR clinical activities.
This position is eligible for telework that requires a minimum of three days a week in the office located in Austin, TX.

Requirements

• Must possess a current, unencumbered Texas Registered Nurse license (or a license from a state that Texas recognizes reciprocity through the Nurse Licensure Compact).
• Knowledge of: Texas Medicaid medical policy, nursing and clinical techniques and procedures, health care laws, rules, standards, and regulations; utilization management and review principles and practices; knowledge of health care practices and acute care services and clinical services for individuals with complex medical needs; knowledge of Medicaid managed care. Knowledge of utilization review and prior authorization software and basic ICD-10 coding, medical diagnoses and procedures; accepted medical treatment patterns and practices; project and quality management.
• Skill in: Written and verbal communication necessary to, develop, maintain, and update unit policies, rules, and guidelines, to consult, teach and provide clear and concise direction, and to clearly explain reports resulting from review findings and data analysis. Microsoft Office Suite including Word and Excel. Communicates effectively in writing and verbally with internal and external stakeholders.
• Ability to: Plan, assign, and provide guidance on the work of others. Work collaboratively and professionally with both internal and external stakeholders; consult, teach and provide clear and concise direction; clearly explain reports resulting from data analysis; Gather, assemble, correlate, and analyze facts and think critically. be a team player; identify appropriate clinical services; prepare, maintain, and present reports; explain and interpret applicable health laws, rules, standards, and regulations; recognize patterns of inappropriate medical necessity determinations; gather, assemble, correlate, and analyze facts; devise solutions to problems; develop and evaluate policies and procedures; Travel independently throughout the state as necessary. Use a personal computer, fax machine, copier, telephone conferencing functions, and components of Microsoft Office Suite and Outlook e-mail.

Nice To Haves

• Bachelor's or advanced degree in nursing preferred, but other bachelor's or advanced degrees or years of experience will be considered.
• Four years’ experience in nursing work or nursing work in an administrative capacity.
• Experience with Texas Medicaid, managed care organizations, authorization regulations and procedures, or utilization review principles and practices preferred.
• Managed care experience preferred.
• Two years supervisory or leadership experience preferred.

Responsibilities

• Responsible for reporting updates to the Director of ACUR and MCUR leadership by keeping abreast of current and upcoming projects within the unit to ensure project timelines are being met. Identifies potential risks and provides proposed solutions. Updates tasks in project management software and other relevant systems, as warranted.
• Responsible for meeting with ACUR clinical managers on a regular basis to coordinate efforts and provide guidance on clinical review projects. Oversee the assignment of projects to ACUR clinical managers.
• Reviews clinical documentation to provide guidance to clinical managers when determining compliance with HHSC managed care contracts and state and federal regulations. Provides clinical expertise to MCUR, OMD, and MCS leadership related to ACUR reviews and projects.
• Works closely with Communications and Planning team in ensuring clinician training is timely and complete. Collaborates with QA and Operations in the use of dashboards and other data relevant in ACUR reviews.
• Evaluates continuous improvement of processes for clinicians and coordinates the implementation of best practices.
• Represents the unit on related topics and communicates with internal and external stakeholders.
• Performs related work as assigned.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level