Nurse III Managed Care Nurse Analyst

TX-HHSC-DSHS-DFPS•Austin, TX

91d•Hybrid

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. Telework opportunities are available for the position. The work location is flexible and is not limited to Austin and the cities listed in the posting.The Nurse III, Managed Care Nurse Analyst, is a senior-level position that reports to an Acute Care Utilization Review Unit’s (ACUR) Managed Care Clinical Review Manager.If you are looking for an opportunity to use both considerable clinical experience and highly developed research and critical thinking skills, this job may be perfect for you.This position is ideal for a registered nurse who wants to work with a team of highly advanced professionals to ensure Texas Medicaid recipients have appropriate access and coordination of medically necessary services through contracted managed care organizations (MCOs) in the STAR, STAR+PLUS, STAR Kids, and STAR Health programs.This position performs complex assessment and analysis of Medicaid MCO utilization management policies and procedures and clinical case files to determine compliance with Texas Medicaid contracts and state and federal regulations.The Managed Care Nurse Analyst must demonstrate an ability to work as an effective team member within ACUR and with other divisions within HHSC, be proactive in seeking input from other staff in the Medicaid/CHIP Division, and work with varying types of medical professionals.Activities include desk reviews of utilization management documents, analysis of contract compliance, various forms of communication with MCO staff and leadership through email, conference calls, webinars, and onsite reviews at multiple MCOs across the state.MCO onsite reviews include overnight travel and case discussion with MCO leadership.

Requirements

Knowledge of Texas Medicaid policy related to clinical services as detailed in the Texas Medicaid Provider Procedures Manual (TMPPM).
Experience with utilization review in authorization of clinical services, case management, managed care utilization review principles and practices.
Knowledge of Health and Human Service Commission programs, including Medicaid/CHIP.
Knowledge of quality improvement principles.
Familiarity with ICD-10 and HCPC/CPT codes.
Excellent computer skills, including Microsoft Office Suite.
Highly proficient in the English language with excellent written, verbal, and interpersonal communication and presentation skills.
Skilled in establishing and maintaining effective working relationships with managers, coworkers, and other staff or program stakeholders.
Ability to present orally and in writing to a professional group.
Demonstrated ability to work independently and function effectively as a member of a team, and under tight deadlines with high-volume workloads.
Highly organized, and the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.
Detailed and task-oriented.
Ability to actively participate in meetings and workgroups.
Must possess a current, unencumbered Texas Registered Nurse license (or a state that recognizes reciprocity through the Nurse Licensure Compact) in good standing.
Minimum three years of nursing experience in a clinical setting required.
Experience with at least one of the following: Texas Medicaid, managed care, utilization review experience in authorization of clinical services, or case management.
Able to travel 25%.

Nice To Haves

Bachelor's degree in nursing preferred.

Responsibilities

Reviews clinical documentation, Medicaid MCO policies and procedures, and authorization criteria.
Participates effectively in discussions of case, policy and procedure reviews with MCO leadership and staff. Conducts interviews with utilization management staff members during onsite reviews.
Provides effective post-review follow-up by actively compiling findings and monitoring MCO activities related to non-compliance.
Demonstrates competency in internal processes and usage of ACUR clinical and utilization management review tools to ensure accurate and consistent findings
Provides clinical review of complaints and inquiries by analysis of clinical documentation. Prepares a written report of findings.
Accurately interprets complex state and federal laws, regulations, and rules related to Texas Medicaid Managed Care during review activities.
Provides consultation as a utilization management subject matter expert for the various activities to include contract procurement activities throughout the lifecycle of Texas Medicaid managed care contracts; training and guidance to internal and external staff, informs and collaborates with internal divisions regarding outcomes.