Job Information
HEALTH AND HUMAN SERVICES COMMISSION Nurse III in Austin, Texas
Job/Position DescriptionUnder 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 FunctionsConducts 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 individualand#146;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%).Registrations, Licensure Requirements or CertificationsMust possess a current, unencumbered Texas Registered Nurse license (or a state that recognizes reciprocity through the Nurse Licensure Compact). Knowledge Skills AbilitiesKnowledge 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 cli https://jobshrportal.hhsc.state.tx.us/ENG/CareerPortal/job_profile.cfm?szOrderID=592599 Copy the URL in the preceding sentence to an Internet Explorer browser to apply to the job directly through the Texas Health and Human Services Career Portal.