Nurse Reviewer

TX-HHSC-DSHS-DFPS•Austin, TX

1d•$5,833 - $6,667•Hybrid

About The Position

The nurse reviewer (NR) works under the direction of the Surveillance Utilization Review (SUR) Regional Director and Regional Managers for the Office of Inspector General. The NR uses technical skills, analytical skills, and clinical expertise to perform highly complex (senior level) reviews of hospital and nursing facility records to ensure adherence to the requirements of Texas Medicaid as well as state and federal law. The nurse reviewer works under limited supervision with considerable latitude for the use of initiative and independent judgment. The NR reviews hospital records to validate medical necessity, accurate diagnoses and procedure codes by reviewing care plans, medical records, and patient assessments to verify adherence to medical coding guidelines, the accuracy of clinical evaluations, and the consistent delivery of quality care in hospital and nursing facilities. The NR reviews nursing facility records to evaluate whether facilities correctly assessed and documented resident needs based on a review of minimum data set (MDS) assessments and medical record documentation. The NR performs other duties as assigned and required to maintain unit operations. Travels approximately 10% of the time with some overnight stays.

Requirements

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 from an accredited school of professional nursing, college, or university is required.
Experience using a personal computer and Microsoft software in a telework/remote environment.
Minimum of 2 years of experience in a program or service area related to hospital, nursing facility, acute care, and/or managed care.

Nice To Haves

RAC-CT (Resident Assessment Coordinator) certified or be willing to obtain certification within six (6) months of start date.
Full time experience in nursing facility administration and/or utilization review is preferred.
Experience with Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) preferred.

Responsibilities

Conducts ongoing retrospective reviews of nursing facility records using technical skills, analytical skills, and clinical expertise to determine whether facilities correctly assessed residents needs, reimbursements were appropriate for the level of care, and care provided was medically necessary; Meets established performance metrics as established by OIG leadership; Applies advanced nursing knowledge to determine whether Medicaid NFs adhere to rules, regulations, written policies, and procedures; and identifies potential fraud, waste and abuse; Maintains confidentiality and HIPAA privacy standards in fulfillment of job duties.
Conducts ongoing retrospective reviews of hospital records using technical skills, analytical skills, and clinical expertise to determine necessity of admission and the accuracy of diagnosis and procedural coding using Federal coding guidelines to validate the accuracy of billing; Meets established performance metrics as established by OIG leadership; Applies advanced nursing knowledge to determine whether Medicaid hospitals adhere to rules, regulations, written policies, and procedures; and identifies potential fraud, waste and abuse; Maintains confidentiality and HIPAA privacy standards while identifying potential fraud waste and abuse.
Interacts professionally with Texas Medicaid providers, external stakeholders, and OIG colleagues in performance of job duties. Follows established policies, procedures, guidance, and direction when conducting reviews. Works under limited supervision with considerable latitude in professional judgement to perform assignments and other duties as assigned and required to ensure the overall efficient functioning of the division. Standards of performance are applied at the time of task assignment and management.
Support investigations and other OIG divisions in the examination of alleged violations of laws, rules, and regulations in Texas Medicaid.