Managed Care Utilization Review

TX-HHSC-DSHS-DFPS • Sulphur Springs, TX

3d • Remote

About The Position

Under the direct supervision of the UR nurse supervisor, the UR Nurse III conducts reviews of assessments, individual service plans (ISPs) and other relevant documentation to evaluate long term services and supports (LTSS) in Medicaid managed care; and to determine compliance with policies, procedures, rules, laws, contract standards, and correctness of needs assessments for Medicaid managed care LTSS. The UR nurse uses an array of evaluation methods, including review of records and face to face interviews with waiver members for validation of service needs and service delivery. The UR nurse uses program knowledge and nursing expertise to determine service needs and quality. This position has moderate latitude for use of initiative and independent nursing judgment in the required evaluations. The UR nurse III will be responsible for complex policy interpretations, validation of, or recommendations for clinical review decisions made by Medicaid managed care organizations (MCOs) and provider agencies. This position will also be responsible for timely and accurate reporting. The UR Nurse III will also be responsible for working collaboratively with MCOs and providers to ensure coinciding and/or mutually-dependent functions are accomplished smoothly.

Requirements

• State of Texas Registered Nurse license in good standing.
• Required to obtain and maintain RUG certification upon hire.
• Knowledge of: nursing techniques and procedures; health care laws, rules, standards, and regulations; medical diagnoses and procedures; accepted medical treatment programs; community health and nursing care principles, practices and procedures; Medicaid and managed care regulations and procedures; utilization management and review principles and practices; and health care needs and services for the aged and disabled as well as pediatric special needs.
• Skill in: organizing work; care and treatment of patients; written and verbal communication necessary to organize, develop, and review unit policies, rules, and guidelines; and to consult, teach, and provide clear and concise directions and reports.
• Ability to: identify appropriate nursing care and other health care services; prepare, maintain, and present reports; explain and interpret applicable health laws, rules, standards, and regulations; organize, coordinate and evaluate nursing activities and delivery of public health services; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, fax machine and copier, telephone conferencing functions, and components of the Microsoft Office suite and Outlook e-mail; travel independently throughout the state as necessary.
• Ability to gather, assemble, correlate, and analyze facts; to devise solutions to problems; to develop and evaluate policies and procedures; and to prepare reports.
• Experience in nursing work.
• Graduation from an accredited four-year college or university with major course work in nursing (BSN or MSN preferred), or from an accredited nursing program.

Nice To Haves

• Experience in program evaluation, Utilization Review , and Long-Term Services and Supports (LTSS) is preferred.
• Experience in pediatrics, adult and geriatric health preferred.
• Managed Care experience preferred.

Responsibilities

• Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.
• Implements UR activities.
• Reviews MCO policies and procedures, nursing activities, medical records, assessments including medical necessity/level of care (MN/LOC), and ISPs, to determine compliance with policies and procedures, correctness of assessments, standards of care, and quality of service.
• Makes recommendations for improvement as a result of the reviews.
• Produces routine and specialized data and information for program reports.
• Responsible for timely and accurate reporting of program activities.
• Informs and collaborates with internal divisions as necessary on program outcomes.
• Interprets complex state and federal laws, regulations, and rules related to the program.
• Perform other duties as assigned.

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