CII HCR QA Reviewer

TX-HHSC-DSHS-DFPS • Austin, TX

5d • Remote

About The Position

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.

This Position schedule is Monday - Friday 8 AM - 5 PM.
Serves as a Quality Assurance Monitoring Specialist with the Quality Assurance Unit. Quality Reviews include Long Term Care, Home and Community Support Services Agency (HCSSA), Health Care Quality/Acute Care (HCQ), and Substance Abuse/Narcotic Treatment Program complaints and self-reported incidents. Reviews daily intakes of all allegations of abuse, neglect, and exploitation received by intake specialists to determine if it is a violation and to ensure timely and accurate triage and prioritization. Edits reports prepared by intake specialists prior to sending electronically to the regional offices for Investigation and to ensure quality control and accountability standards are maintained. Analyzes and interprets Regulatory Services policies, procedures and regulations. Provides consultation to agency staff, providers, advocates, consumers, legislators and other agencies. Serves as a liaison between the Complaint Intake Unit and regional field operations staff. Assists with the intake of complaints, incidents, and requests for information. Performs related work and may participate in special projects and workgroups as assigned. Interprets policies, procedures, rules, regulations and standards and communicates on a complex level with others to exchange or verify information, respond to inquiries, address issues or resolve problems. Performs other duties as assigned.

Requirements

• Any one of the following Registrations, License Requirements or Certifications are required: Licensed Vocational Nurse (LVN) or Registered Nurse (RN), SMQT, Medical Technologist/Laboratory Technician, Surgical Assistant, Emergency Medical Technician, End Stage Renal Disease/Dialysis Technician, Other License/Degree/Certification in Health Care.
• Knowledge of state and federal laws and regulations related to regulatory programs.
• Knowledge of health care principles, practices, and procedures.
• Ability to effectively communicate, organize and present information, with others orally and in writing to provide information.
• Ability to present professional and knowledgeable information to internal and external stakeholders.
• Ability to use judgment, make effective decisions and prioritize work.
• Ability to analyze and solve problems.
• Bachelor’s or Associate's Degree from an accredited college or university or Nursing Licensure (RN/LVN).
• Applicants must be able to work Monday thru Friday 8 AM to 5 PM.

Nice To Haves

• Experience in Long Term Care Program, HCSSA Program, or Acute Care Program Preferred.

Responsibilities

• Performs quality assurance reviews of long-term care and non-long-term care complaints and incidents to ensure accuracy/compliance with applicable Federal and State regulations. Quality assurance reviews ensure appropriate triage of priority, facility and patient history, allegations, and conditions of participation/coverage, if applicable.
• Evaluates long-term care and non-long-term care complaints and incidents related to abuse/neglect/exploitation of children, elderly, individuals with mental illness, or individuals with intellectual disabilities to ensure the assigned priority is in alignment with Federal and/or State regulations. Includes notifying regional staff of 24-hour priority or 2-day priority intakes.
• Performs quality assurance reviews for complaints to ensure the facility/agency is within Federal or State Jurisdiction. When found to be non-jurisdictional, referrals are made to other agencies, such as the Ombudsman, the Joint Commission, and the Medical Board.
• Interprets long-term care and non-long-term care policies, procedures, rules, regulations, and standards for individuals within Complaint and Incident Intake.
• Communicates on a complex level with CII Staff, CMS Regional staff, State Regional staff, and other CII customers to provide, exchange, or verify intake information, answer inquiries, address issues,  or resolve problems
• Identifies trends within internal policies and procedures and collaborates with management or workgroups to develop a resolution to ensure compliance with federal and state requirements.
• Completes Quality control operations and procedures by routing long-term care and non-long-term care high profile complaints and incidents when the resident/patient/client is a minor under Permanent Managing Conservatorship or involves a legislative inquiry or becomes of public interest.
• Serves as liaison for assigned areas on complex issues with agency staff and outside entities such as the CMS, Joint Commission, DFPS, and DSHS.
• Maintains current knowledge in assigned areas by reviewing literature (CMS SOM Chap 5, Appendix Q, TAC rules, and Provider Letters), attending meetings/seminars, or communicating with other professionals.

Benefits

• comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees
• defined benefit pension plan
• generous time off benefits
• numerous opportunities for career advancement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees