Medicaid Modernization and Nurse Policy Analyst (Nurse IV)

TX-HHSC-DSHS-DFPS • Austin, TX

21d

About The Position

If you are a nurse (RN) looking for a path to a health policy career, then this is one of them. Do you enjoy researching, writing, and keeping current with the latest evidence-based practices? Are you technically savvy, enjoy the world of claims system processing, modernizing systems, and effecting solutions?The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Nurse IV Medicaid Modernization and Policy Analyst.The Nurse IV position reports to a Medical and Dental Benefits Policy (MDBP) Manager in the Office of Program and Policy. The Nurse IV Medicaid Modernization and Policy Analyst performs complex medical benefits policy analysis, benefit language development, policy implementation, and provides policy consultation. The Nurse IV position will also be required to work on Medicaid modernization projects. This position will work closely with other MDBP staff, HHSC Operations staff, Information Technology specialists, claim system administrators, and others in the ongoing efforts to modernize Medicaid systems and assist in technology change decisions. Medicaid modernization is an agency-wide project to streamline and update the highly complex network of interconnected systems that support Texas Medicaid delivery.This position is expected to have experience and strong working knowledge of CPT, HCPCS, NCCI, ICD, revenue codes, modifiers, groupings, system crosswalks, claims system functions, current medical billing and coding practices, and knowledge of taxonomies and provider types. The nurse in this position will also research, review, and revise medical and dental benefit policy language across the Medicaid handbooks and provider manuals while also ensuring accurate setup and support of the language in the claims system or other related technology updates.

This position requires excellent writing skills and strong research skills, including experience conducting comprehensive literature reviews using credible evidence-based sources, health literature electronic databases, and must be able to synthesize and communicate complex findings for clinical and non-clinical audiences. The Nurse IV will apply their findings to medical benefits for developing policy within the Medicaid program. These findings must be interpreted correctly in accordance with the Texas Medicaid program requirements, as well as state and federal regulations.
The nurse in this position must be proactive in seeking input from other staff in MCS and demonstrate the ability to work as an effective team member with other divisions within HHSC and other HHS agencies and vendors. The Nurse IV Medicaid Modernization and Policy Analyst in this position will be asked to participate in various workgroups and must work well individually and with peers. This position works under the general direction of an MDBP Manager with a high degree of latitude for the use of initiative and independent judgment.

Requirements

• Must have a current license to practice as a Registered Nurse (RN) in Texas or a state that recognizes reciprocity through the Nurse License Compact.
• Graduation from an accredited college or university with major course work in nursing, healthcare administration, public health, public policy, or a related field.
• Experience in analyzing clinical research or best medical practices and applying findings to work.
• Knowledge of Health and Human Services agencies and programs
• State and Federal Medicaid Plan statutes and regulations
• Medical vocabularies, HCPCS, CPT, NCCI and ICD coding information
• National medical billing and coding standards
• Provider enrollment standards
• Clinical practice guideline evaluation or development
• Clinical quality assessment or improvement practices
• Skill in Quality assurance of medical policy language
• Project planning, evaluation, and implementation
• Establishing and maintaining effective working relationships with managers, co-workers, and other staff or program stakeholders
• Researching and conducting comprehensive literature reviews using scholarly electronic databases and medical journals
• Reviewing medical professional organizations’ recommendations for best practices
• Evaluating the quality and levels of evidence presented in the literature
• Synthesizing findings for clinical and non-clinical audiences,
• Effectively applying findings to policy development
• Clinical research or health care delivery
• interpersonal communication and presentations
• Written and oral communication, including making public presentations, and writing technical information into understandable plain-language formats
• Use of Microsoft Office products and applications (Word, Excel, PowerPoint, Teams, SharePoint, etc.)
• Ability to Lead or participate in special projects and coordinate across teams and business areas
• Effectively communicate, facilitate meetings, and maintain working relationships
• Exercise critical thinking and creative problem-solving techniques in a highly complex environment
• Participate and provide recommendations in technology systems-oriented workgroups
• Work cooperatively as a team member in a fast-paced, deadline-orientated environment
• Work independently and perform work with a high degree of attention to detail
• Manage several projects concurrently and juggle competing priorities
• Produce well-written, well-researched resources, documents, responses, and rationales.
• Effectively facilitate meetings and establish and advance agenda goals
• Be flexible, to pivot from a known present-state to an unknown future-state requiring adaptability, risk management, and planning skills for evolving possibilities

Nice To Haves

• Clinical coding certificate is strongly preferred but may not be required if the nurse can demonstrate clinical coding competence in their work history experience. Coding Certificate is preferred through the American Health Information Management Association AHIMA (CCS-P, CCS) or American Association of Professional Coders AAPC (COC, CPC, CIC) or Practice Management Institute PMI (CMC).
• Experience with literature reviews or scholarly research on clinical topics.
• Experience with applying medical billing and coding standards to work.
• Experience with publicly funded health care programs, such as Medicaid.
• Experience with updating and modernizing technology systems.

Responsibilities

• (30%) Researches, analyzes, evaluates, and synthesizes peer-reviewed literature, evidence-based clinical practices, complicated federal and state regulations, client information, and claims processing information for medical benefit reviews and application to Medicaid medical and dental benefits. Researches and applies findings to the development of benefit policy language. Synthesizes complex technical medical information verbally or in writing for clinical and nonclinical audiences. Consults with stakeholders to address Medicaid program benefit policy issues.
• (30%) Leads and participates in modernization projects related to claims system coding modernization, national and local coding, and policy language quality assurance. Responsible for reviews and updates to MDBP benefits. Develops new benefits for Medicaid MDBP policy. Identifies eligibility standards and authorization requirements, reviews and incorporates requirements into benefit language. Collaborates with staff in MDBP, HHSC, other state agencies, and the claims system administrators for program benefit policy development, planning, and implementation. Serves as a clinical subject matter expert in the development and review of program benefit policy, medical and dental benefit coding, and assists in technology change decisions. Develops, reviews, and provides comments on Medicaid materials intended for use by vendors, providers, managed care organizations, and other stakeholders.
• (20%) Participates in quality assurance activities through the development and review of Medicaid program medical and dental benefits, including reviewing documentation, reviewing and approving medical benefits language for internal and forward-facing publications. Documents and tracks research, reviews policy development, discusses and drafts benefit policy changes. Researches and responds to stakeholder inquiries as a representative of HHSC. Maintains organized electronic files of activities and shares with staff and partners as appropriate. Assists in the review, response, and referral of complaints concerning billing, medical services, provider enrollment, or other related issues.
• (10%) This position will work on high priority and critical projects and must be proactive in seeking input from other staff in MCS. The Nurse IV must demonstrate the ability to work as an effective team member. Leads or participates in special projects as requested by management. Positively represents department, agency, and the state in conferences and meetings, including public presentations, and as an ongoing MDBP representative on various committees and teams. Facilitates and participates in policy meetings with internal, intra-agency, vendor, stakeholder, public, or legislative membership. Prepares project updates, summaries, reports, or other documents and keeps management informed on pertinent issues. Responds to internal and external communications and requests in a timely manner. Identifies the need to communicate and consult with external stakeholders as necessary.
• (10%) Develops complex memos, briefs, and other documents for HHSC leadership regarding medical benefit changes and ongoing modernization activities. Functions as a resource for other state staff providing guidance, recommendations, or direction. Assists in decision-making. Position may be assigned as lead for specific MDBP legislative bill assignments, to complete related analysis and activities, including bill implementation. Other duties as assigned, may include actively participating in or serving in a supporting role to meet the agency's obligations.

Benefits

• 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.

What This Job Offers

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