Nurse Analyst

TX-HHSC-DSHS-DFPS • Austin, TX

19d • Hybrid

About The Position

The OMD Nurse Analyst (Nurse III) actively participates in and supports multiple activities of Office of Medical Director (OMD), Medicaid and CHIP Services (MCS), Texas Health and Human Services (HHSC). In particular, this position provides a variety of clinical and organizational supports as part of the team evaluating provider appeals of retrospective utilization reviews. The mission of MCS is to improve the health of Texas and to deliver quality, cost-effective services to Texans, while aligning MCS programs with state public health priorities. OMD provides clinical consultation and guidance to other areas within MCS, throughout the Agency, and to external stakeholder organizations. OMD also leads the utilization review team of MCS, which is charged with ensuring that individuals receive medically necessary, cost-effective services.

Retrospective utilization reviews subject to appeal are initially performed by Office of Inspector General (OIG) or HHSC contractors to assure Medicaid providers are delivering quality and cost-effective services to Medicaid beneficiaries, according to state and federal laws, regulations, and rules. The OMD Nurse Analyst will evaluate provider appeals of these utilization reviews by examining medical records and documentation submitted by the provider upon appeal, evaluating medical necessity for the level of care billed or appropriate coding for APR-DRG calculation. This work involves complex and technical analysis and requires knowledge of hospital care, office care, Texas Medicaid policies, and state and federal laws related to care and billing. It also involves knowledge of the various code sets, such as ICD-9, ICD-10, CPT, and DRG employed in medical billing. This position communicates in verbal and written form with providers and multiple stakeholders, so excellent writing and communication skills are essential.
The OMD Nurse coordinates with external stakeholders, such as Medicaid-enrolled providers, regarding appeal processes, including by development of training materials and coordination of case conference meetings. The position also interacts with other departments within HHSC and its contractors, providing internal policy recommendations regarding medical benefit policies and appeal processes. The OMD Nurse Analyst will also serve as the clinical subject matter expert for official coding guidelines and conventions for medical policies. This nurse may provide Medicaid hospital staff and UR nurse reviewers with ongoing education.
The OMD Nurse Analyst may assist with the disability determination process in accordance with Social Security Administration guidelines. This will involve serving as a clinical subject matter expert on medical conditions and impairments, performing research, review and evaluation of disability claims and related appeals, and providing testimony at administrative hearings in support of medical decisions rendered in the disability determination process.The OMD Nurse Analyst may assist with determination of eligibility for Waiver programs by analyzing documentation of a person’s diagnoses and conditions and comparing them with eligibility criteria, and by providing testimony at administrative hearings in support of medical decisions rendered in the eligibility determination process.
The OMD Nurse Analyst must be able to evaluate and synthesize information from a variety of sources and apply it to current and new benefit policies for the Texas Medicaid/CHIP program. Information may come from current medical practice, peer-reviewed literature, professional associations, Medicaid programs of other states, HHSC leadership, and state and federal rules. The OMD Nurse Analyst in this position must seek input from other staff in MCS and demonstrate the ability to work as an effective team member with internal and external stakeholders. The OMD Nurse Analyst coordinates special projects as needed.

The OMD Nurse Analyst works under minimal to moderate supervision, with latitude for the use of initiative and independent judgment. The position reports to the Chief Medical Director or an Associate Medical Director for MCS.

The ideal candidate thrives in an environment that emphasizes teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to accomplish tasks accurately and correctly.

Requirements

• Knowledge of medical diagnoses, procedures and accepted medical treatment patterns.
• Knowledge of medical necessity, coding, and Medicaid claims principles.
• Knowledge of the Medicaid Program and Children's Health Insurance Program, to include Medicaid waiver programs.
• Knowledge of local, state, and federal laws and regulations related to privacy and medical practice.
• Knowledge of appropriate ICD-10-CM coding, APR-DRG assignment, and Medicaid inpatient claims filling.
• Knowledge of and expertise in the process for developing clinical practice guidelines.
• Knowledge of methods of analysis, detection, and measurement of fraud, waste, and abuse.
• Knowledge of quality assurance principles.
• Skill and experience in working as a nurse in clinical situations, especially in hospital settings.
• Skill in researching and analyzing evidence-based literature.
• Skill in problem solving.
• Skill in project planning, evaluation, and implementation.
• Skill in the use of computers and software programs, including the Microsoft Office suite.
• Skill in establishing and maintaining effective working relationships with managers, co-workers, and other staff or program stakeholders.
• Ability to apply nursing knowledge, practices, and procedures to components of the job and in consultation.
• Ability to interpret medical documents, including charts, narratives, diagnosis lists, and plans of treatment.
• Ability to interpret and apply policies, procedures, laws, rules, and regulations.
• Ability to perform utilization review, including medical necessity determinations.
• Ability to work alone and in teams.
• Ability to work and maintain documentation in an organized manner.
• Ability to express ideas clearly, accurately, and concisely in writing and orally.
• Ability to work independently and prioritize workload assignments to meet established deadlines.
• Ability to demonstrate excellence in customer service.
• Ability to interact effectively and professionally with persons from diverse cultural, socioeconomic, educational, racial, ethnic, and professional backgrounds.
• Ability to work independently with limited supervision.
• Ability to maintain a regular and predictable work schedule.
• Licensed to practice as a Registered Nurse in the State of Texas or in a state recognized under the Compact Licensure Agreement. License is current and in good standing.
• Graduation with bachelor’s degree or above from an accredited school of professional nursing.
• At least five (5) years of experience working as a nurse in a clinical environment.
• At least two (2) years of experience with one or more of the following: quality assurance, quality improvement, utilization review, utilization management, and/or medical appeals processes.

Responsibilities

• Clinical Case Review and Interdepartmental Consultation - Uses advanced nursing knowledge, technical and analytical skills to perform review and evaluation of documentation submitted by Medicaid providers or clients for reconsideration of adverse determinations.
• Consistently and accurately uses current clinical code sets, such as ICD-10-CM and CPT, and guidelines for coding diagnoses and procedures.
• Applies evidenced-based research to medical benefits policy reviews.
• Detects patterns of inappropriate claims filing, including coding issues, and collaborates as needed with authorities or other HHSC departments in responding.
• Establishes and maintains effective working relationships and communication with team members and staff from other HHSC departments and other stakeholders.
• Collaborates with staff from HHSC and other State agencies for program benefit policy development, planning and implementation.
• Assists with the review, development, and implementation of materials intended for use by Medicaid vendors, managed care organizations, providers, and other stakeholders.
• Provides ongoing education to Medicaid providers and OIG Utilization Review (UR) nurse reviewers.
• Reviews, analyzes, researches, and develops medical, dental and mental health benefit policy, providing complex technical medical information verbally or in writing.
• Responds in a timely manner to internal and external inquiries and requests for information.
• Special projects and workgroups - Participates in workgroups and public meetings engaged in research, analysis, and evaluation of policy issues or initiatives.
• Positively represents the department, agency, and State in meetings, committees, teams, and conferences, as directed.
• Coordinates with stakeholder workgroups to address Medicaid program benefit policy issues.
• Prepares project updates, summaries, reports, or other documents and informs leadership and other staff as needed.
• Quality Assurance - Participates in quality assurance activities through: -Development and review of medical, dental and mental health benefits, including documenting discussions, research tracking, policy development, and drafting of program benefit policy changes. -Assisting in the review and referral of complaints concerning medical and other provider services. -Researching and responding to provider or manufacturer questions or concerns. -Maintaining organized documentation of activities and sharing with partners, as appropriate.
• Regulation Review - Reviews, analyzes, and comments on regulations affecting benefit policy.
• Conducts special projects or other duties as assigned in support of the Medicaid and CHIP Services Division.

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
• Number of Employees: 1-10 employees