Utilization Review Nurse

Nurse II

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.

Essential Job Functions:

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

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, televideo, or telephonic interviews 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, determines 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. (10%)

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%)

Works collaboratively across MCS to identify innovative and effective solutions for clients and staff (5%)

Registrations, Licensure Requirements or Certifications:

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. 

Qualification as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required. 

Must have a valid Texas Driver License.

Knowledge Skills Abilities:

Meets the criteria for designation as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required.

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.

Thorough knowledge of ID and other developmental disability related conditions, HCS, TxHmL, CLASS, DBMD, CAS, and ICF/ID program rules, service array and billing guidelines, local authority functions and waiver service system.

Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports.

Awareness of federal and state laws relating to long term care and other Medicaid and non-Medicaid services and programs.

Knowledge of program planning, implementation and evaluation, and continuous quality improvement.

Ability to communicate effectively, both orally and in writing.

Ability to interpret statistical information.

Ability to multi-task, handle stress and meet deadlines.

Ability to work collaboratively across MCS to accomplish objectives.

A keen attention to detail and the ability to implement creative solutions to problems.

Able to balance team and individual responsibilities.

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.

Initial Screening Criteria:

Two-year experience working as a Registered Nurse (RN).

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.

Must meet the federal definition of a Qualified Intellectual and Developmental Disability Professional as defined in 42 Code of Federal Regulations 483.430(a). Must have at least one year of experience working directly with persons with intellectual disability or other developmental disabilities.

Must be able to travel 75% of the time.

Experience in utilization review, or quality assurance activities in long term services and supports for the aged and disabled preferred.