Utilization Review Nurse

TX-HHSC-DSHS-DFPS • Corpus Christi, TX

23h

About The Position

The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Nurse II. MCS is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by ensuring individuals served in our 1915(c) waiver programs and Community Attendant Services (CAS) receive the appropriate type and amount of service.
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 do things right even when what is right is not easy.
Under the direct supervision of the Utilization Review Nurse Manager, the utilization review (UR) nurse: reviews and evaluates individual's records, individual service plans (ISPs), patient assessments, documentation related to Title XIX and Title XX, and state plan Medicaid community services for aged and disabled persons and individuals with intellectual and developmental disabilities (IDD); and conducts face to face interviews with individuals enrolled in the Community Attendant Services (CAS), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS), and Texas Home Living (TxHmL) programs to determine service justification. Based on the in-person, teleconference or telephone interview assessment, desk review and evaluation of services, the UR nurse uses program knowledge and nursing expertise to determine appropriateness and quality of services, cost effectiveness of the service plan, validates determinations of health service needs, and makes service authorization decisions.
The UR nurse conducts a variety of quality assurance reviews, and quality improvement studies. The UR nurse evaluates assigned Level of Need (LON) determinations in the IDD waiver programs when assigned to do so. This position works collaboratively with other UR nurses and regional staff to implement an effective statewide UR program and to ensure UR policies and procedures are applied consistently. This position works under the general supervision of the UR Nurse Manager, with moderate latitude for use of initiative and independent judgment.

 The Nurse II Field Reviewer attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Requirements

• Must be licensed as a professional Registered Nurse (RN) in the state of Texas or a state that recognizes reciprocity through the Nurse Licensure Compact.
• Must have one year’s experience in the provision of direct services to persons with an intellectual disability.
• Knowledge of nursing health care laws, rules, standards, and regulations, medical diagnoses and procedures, community health and nursing care principles, quality management, utilization management, health care needs and services for elderly and disabled, Medicaid waiver program standards, policies, and procedures and government regulations and oversight mechanisms.
• Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports.
• Ability to: explain and interpret applicable health laws, rules, standards, and regulations; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, copier, Microsoft Office suite and Outlook e-mail; travel throughout the state as necessary.
• Must have a valid Texas Driving License and able to travel 15% of the time at current, this may change in the future.
• Two-year experience working as a Registered Nurse (RN).
• Must meet the federal definition of a Qualified Intellectual and Developmental Disability Professional.
• Must have one year’s experience in the provision of direct service to persons with intellectual disability.
• Must be able to travel 75% of the time.
• Able to use a personal computer and related Microsoft Office software applications.

Nice To Haves

• Graduation from an accredited four-year college or university with major course work in nursing preferred, or from an accredited nursing program. BSN preferred, experience and education may be substituted for one another.
• Experience in utilization review, or quality assurance activities in long term services and supports for the aged and disabled preferred.

Responsibilities

• Conducts desk reviews of required documentation for Health and Human Services Commission (HHSC), Medicaid Long Term Care Waiver Programs and Community Attendant Services (CAS). Participates in onsite reviews of the individuals identified in the random sample. Reviews, evaluates, and documents services provided to aged and disabled persons and persons with intellectual disability to validate service needs, service provision, determine appropriateness, quality, and cost effectiveness of services. (35%)
• Makes service authorization decisions on difficult, complicated, and/or targeted cases. (20%)
• Conducts a variety of quality assurance reviews and quality improvement studies and evaluates compliance with Medicaid program service requirements, state rules, regulations, policies, and procedures. (15%)
• Works collaboratively with other UR nurses through routine and ad hoc meetings to implement an effective statewide UR program and to ensure UR policies and procedures are applied consistently. (10%)
• Develops, provides resources and technical assistance to regional staff and providers. (10%)
• Testifies as the Subject Matter Expert (SME) in Medicaid fair hearings related to appealed service reductions or denials. (5%)
• Produces routine and specialized data and information for program reports. (5%)

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
• Education Level: No Education Listed