Registered Nurse (RN) - Med Surg
Austin State Hospital
Austin, TX

Nurse III

Under the general supervision of the Utilization Review (UR) High Needs Quality Assurance Manager, the High Needs UR Nurse III is responsible for the evaluation of long term services and supports (LTSS) activities for High Needs individuals enrolled in the following programs: STAR Kids, STAR+PLUS, Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS), and Deaf Blind with Multiple Disability (DBMD) including but not limited to clinical review of medical records, assessments, planning documents and other relevant documentation for validation of service needs and service delivery; consultation and development of recommendations on individual cases involving service appropriateness; and determination of compliance with policies, procedures, rules, laws, contract standards, and correctness of needs assessments for Medicaid managed care LTSS. 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. Essential Job Functions: Conducts reviews on all high needs cases including: individuals transitioning out of STAR Kids, General Revenue (GR), Money Follows the Person Limited Nursing Facility Stay for the Medically Dependent Children Program (MDCP), and any other requests, as assigned with a focus on nursing interventions, treatments and service delivery. (30%) Determines compliance and provides MCO oversight of nursing activities, medical records, assessments including medical necessity/level of care (MN/LOC), STAR Kids-Screening and Assessment Instrument (SK-SAI) and ISPs for accuracy. Standards of care, and quality of service. Makes recommendations for improvements as a result of reviews. (15%) Determines compliance with Medicaid program service requirements, state rules, regulations, policies and procedures for individuals with diagnoses of Intellectual and Developmental Disability (IDD) to validate service needs and service provision, determine appropriateness, quality, and cost effectiveness of services being authorized on an individual's plan of care. (15%) Works collaboratively with colleagues through routine and ad hoc meetings to ensure utilization review policies and procedures are applied consistently (5%). Develops, provides resources and technical assistance related to high needs transitions, to the agency staff, managed care organizations, IDD waiver community provider base, advocacy groups, external stakeholders, program participants and their families. (15%) Testifies as the subject matter expert in Medicaid fair hearings related to appealed service reductions or denials for IDD high needs transition cases. (10%) Researches and responds to legislative inquiries related to High Needs Cases.(5%) Participates in special projects upon request (5%). Knowledge Skills Abilities: Knowledge of Texas Medicaid policy related to clinical services and service delivery as detailed in the Uniform Managed Care Contract Manual and other applicable Medicaid contracts, STAR+PLUS, STAR Kids, and STAR Health handbooks, Texas Administrative Code, and 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. Excellent computer skills, including Microsoft Office Suite. Ability to communicate effectively both orally and in writing. 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. Detail and task-oriented. Highly proficient in the English language with excellent written, verbal, and interpersonal communication and presentation skills. Ability to actively participate in meetings and workgroups. Skilled in establishing and maintaining effective working relationships with managers, coworkers, and other staff or program stakeholders. Knowledge of quality assurance and improvement measures and principles. Familiarity with ICD-10 and HCPC/CPT codes. Registration or Licensure Requirements: Must possess a current, unencumbered Texas Registered Nurse license (or a state that recognizes reciprocity through the Nurse Licensure Compact). Initial Selection Criteria: Bachelor's degree in nursing preferred. Must be a Register Nurse with a valid RN license. Minimum three years nursing experience in a clinical setting required. Must be a QDIP with at least one year of experience working with individuals with intellectual/disabilities or related conditions. Knowledge of ID and other developmental disability related conditions. Experience with at least one of the following: Texas Medicaid, managed care, utilization review experience in authorization of clinical services, or case management. Experience testifying or presenting to groups preferred. Additional Information: Part-time telework opportunities available following successful completion of initial orientation period or in accordance to business needs. Information on application must clearly state how applicant meets the initial selection criteria in the Summary of Experience section of the application." MOS Code: Note: Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include: 68C, 66N/P/W, 290X, 46FX, 46NX, 46SX. 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. Top 10 Tips for Success when Applying to Jobs at HHSC and DSHS