Nurse IV

    Texas Health & Human Services Commission
    11501 Burnet Road, Austin, TX 73301
    Full-time
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    Job Description


    Nurse IV is hired by and reports to the Manager for Utilization Review(UR) and Lock-In (LI) Program(s). Position provides managerial/supervisory oversight of day to day activities related to the Office of Inspector General (OIG) Hospital UR and the LI program for state office and region staff across five regions. The position performs highly advanced work as subject matter expert providing oversight of hospital program. Duties include analysis, development, and management of policies, guidelines, procedures, and standards to achieve goals and work plan for the OIG-UR. Analyzes and recommends policy and procedure for compliance with federal, state regulations and process improvement. Implements UR strategies managing various functions including oversight and coordination of staff who perform hospital reviews for medical necessity, diagnosis related group(DRG)validation and quality of care. Coordinates development of selection criteria for claim review of fee for service and managed care (MCO)paid services. Consults with providers, associations, and state agencies including HHS/Medicaid CHIP, Office of Medical Director, and Vendor Drug. Provides subject matter expertise to other divisions of OIG. Troubleshoots and resolves issues for reviewers. Analyzes and develops responses to legislative inquiries. Oversees LI work processes including referrals and audits. Consults with MCOs through OIG initiatives and teleconference providing training and process improvement. Develops and implements education and training for reviewers for inter-rater reliability. Provides subject matter expertise for quality control for LI and UR. Requires minimal direction and has extensive latitude for the use of initiative and independent judgment.

    Essential Job Functions:
    Oversees hospital review process with state office staff including training, assignments, medical record/document review, tracking for hospital post-review activities including coding/quality, and physician reviews. Responds to inquiries from providers on reviews and appeals process. Advises nurse reviewers, region managers, quality control team for policy interpretations and problem resolution. Consults with appropriate state agency, HHS/Medicaid CHIP, Office of Medical Director, and Vendor Drug, for policy and inquiries. Oversees lock-in referral and audit processes for recipients under fee for service and managed care. Coordinates appeal requests for lock-in with Fair Hearings Office. Collaborates with quality control team for questions, issues, and subject matter expertise for the resolution process reviewing documentation, review decisions, and provides final program interpretation. Monitors work product for accuracy, timeliness, and provides training for process improvement. Provides manager with individual staff accomplishments and feedback for performance planning and evaluations (30%)
    Monitors performance of hospital reviews to request claims for sample quarters by tracking completion, addressing exceptions, and providing results to management. Monitors performance measures related post review activities including weekly project updates on open claims for coding, physician review, and lock-in referral completion. Monitors annual work plan implementation supporting training needs through education of policy and procedure and compliance with federal and state regulations. Actively participates in and implements division strategic plan for hospital and lock-in program. Identifies potential fraud, waste, and abuse analyzing and facilitating referrals for audit, investigation, and inspections (25%).
    Develops new hire and annual training agenda and content for region nurse reviewers. Reviews and recommends policy and procedure for compliance with federal and state regulations and process improvement at least annually. Incorporates recommendations and updates in trainings including any managed care or fraud initiatives. Ensures training supports inter-rater reliability and compliance throughout review process by reviewing and educating on policy, procedure, and quality control findings for hospital and lock-in. Coordinates cross-training with hospital utilization review as required for nurse specialists. Coordinates training as requested for new physician consultants (25%).
    Provides strategic planning for maintenance, development, and enhancements for case management, case processing and case tracking systems for OIG-UR and Lock-In program with OIG-IT and contractor. Identifies business processes and requirements for updates and revisions in writing and in work group meetings for hospital and lock-in. Performs user acceptance testing on technical changes. Analyzes current application issues for problem resolution and process improvement including for managed care reviews. (10%).
    Represents OIG-UR and Lock-In program internally and externally at meetings and other forums. Develops responses to inquiries from legislators, executive leadership, other OIG divisions and state agencies upon request. Coordinates responses for external stakeholders and audits with director, manager, and team with written or verbal feedback to address accuracy and consistency with program policy and procedure. Acts in absence of manager and director for OIG hospital and lock-in programs (10%).

    Knowledge Skills Abilities:
    Knowledge of federal and state laws governing Medicaid policies and procedures for acute care services and vendor drug program.
    Knowledge of managed care and contract requirements.
    Knowledge of nursing practices and procedures, medical diagnosis procedures and accepted medical treatment patterns and its application to components of job and in consultation.
    Knowledge of or ability to apply methods of analysis, detection, and measurement of fraud, waste, or abuse.
    Knowledge of quality improvement processes.
    Knowledge of strategic planning, objectives, goals and plan implementation.
    Knowledge of evidence-based guidelines and application to medical services.
    Ability to interpret and apply policies and procedures and regulations.
    Ability to develop, revise and apply policies, procedures and regulations.
    Ability to use personal computers, related software, and create concise reports as necessary.
    Ability to manage program activities.
    Able to work in a team environment across divisions and agencies.
    Skill managing multiple, conflicting, priorities without jeopardizing deadlines.
    Skill communicating effectively in both written and oral communication.
    Skill establishing and maintaining effective working relationships.
    Skill providing education, training, and feedback including presentations for both internal and external audiences.

    Registration or Licensure Requirements:
    Licensed as a Registered Nurse in the state of Texas or in a state recognized under the Compact Licensure Agreement.

    Initial Selection Criteria:
    Prior work history and knowledge. Currently licensed as a Registered Nurse in the State of Texas or in a state recognized under the Compact Licensure Agreement. Graduation from an accredited school of professional nursing, college, or university is required. Knowledge of coding guidelines, coding experience or coding certification highly desirable. Ability to travel 25% of time. Ability to use personal computers and related software. Full time experience in acute care hospital; hospital utilization review preferred; supervisory or coordination experience preferred; Lock-in program, use of evidence-based guidelines and managed care experience is desirable.

    Additional Information:
    Requisition # 449406
    Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Upon final selection and contingent offer, candidate must provide a certified copy of a college transcript. The OIG is responsible for preventing, detecting, auditing, inspecting, reviewing, and investigating fraud, waste, and abuse in the provision of HHS in Medicaid and other HHS programs. Potential employees of OIG are subject to criminal background checks in accordance with the HHS Human Resources policy. Selected applicants must submit to a name-based, or in some instances a fingerprint based, criminal background check through Texas Department of Public Safety (DPS) to determine if an applicant has a conviction for a Class A misdemeanor within the last five years or a felony that constitutes a bar to employment.

    The posted salary range reflects the minimum and maximum allowable by state law. Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual.

    HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

    In compliance with the Americans with Disabilities Act (ADA), HHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

    MOS Code:
    Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to: 68C, 66N/P/W, 290X, 46FX, 46NX, 46SX. All active duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information see the Texas State Auditor's Military Crosswalk at http://www.hr.sao.state.tx.us/Compensation/JobDescriptions.aspx

    HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

    I-9 Form - Click here to download the I-9 form.

    In compliance with the Americans with Disabilities Act (ADA), HHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

    Posting ID: 555358576Posted: 2020-05-21