Consultative Examination Review Specialist

2 weeks ago

Austin, United States Texas Department of Aging & Disability Services Full time
Job Description:
The Consultative Examination Review Specialist (CERS)/Nurse III performs highly complex consultative and technical work in support of case adjudication activities. Reports to and is selected by the Directorate Manager (DM) of Medical Relations (MR). Works under limited supervision with moderate latitude for the use of initiative and independent judgment.

The CERS performs highly complex technical review and analysis of procured consultative diagnostic studies and examination reports to assess compliance with Social Security Administration (SSA) program protocols. The CERS provides advanced technical assistance in support of case adjudication activities. Exercises both initiative and sound decision-making skills. The CERS serves as subject matter expert and resource contact for the adjudicative and management staff on issues involving the completeness, timeliness, and internal consistency of purchased examinations, respiratory studies (pulmonary function studies, arterial blood gas studies, carbon monoxide diffusion capacity studies) and other high risk studies (e.g. ETT) used for case adjudication purposes. Responds to inquiries regarding program protocols for respiratory studies, interprets rules, regulations, policies, and procedures related to the performance of respiratory studies, conducts quality assurance reviews of consultative respiratory studies, prepares written appraisal reports, and takes remedial action with medical service providers where appropriate. Interprets and evaluates evidence of record respiratory studies for case adjudication purposes, develops and maintains data files of respiratory study equipment by brand/model and their capabilities, serves as a subject matter expert for Medical Relations in recruiting and maintaining a panel of consultative respiratory study providers, provides guidance and technical assistance to consultative examination panelists regarding protocols for respiratory studies, provides guidance and technical assistance to the Payment Processing Center in resolving payment issues for procured respiratory studies, tracks and trends quality data from the review of diagnostic studies and examinations, and generates reports for the purpose of provider evaluation and oversight. Assists in the development of intra-agency policies and procedures related to consultative respiratory studies, evaluates ongoing performance of consultative respiratory study providers and provides recommendations to Medical Relations for improvement. May also assist in reviewing and evaluating key/volume providers.

This position occasionally requires work during the weekends, holidays, and before or after normal business hours. DDS employees perform all business functions for SSA, using the federal SSA network and equipment. Homeland Security Presidential Directive (HSPD)-12 security clearance is required.
Essential Job Functions:
Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Performs technical review and analysis of respiratory studies and other high-risk studies received in medical records and purchased consultative examinations to assess compliance with SSA program protocol.

Conducts quality assurance review and assessment of consultative examination reports, laboratory tests, and ancillary studies in accordance with SSA's consultative examination oversight plan and DDS' internal operating procedures to determine compliance with program regulations, policies, and procedures.

Establishes standards for customer-focused communication and coordination within areas of responsibility and with all internal and external associates and customers.

Serves as subject matter expert for Medical Relations in terms of recruiting and maintaining a consultative panel of "high risk" study providers.

Develops and maintains a datafile of respiratory study equipment (brand/model) and their capabilities. Analyzes the compilations of data submitted and recalculates mathematical formulas as needed.

Provides expert consultative assistance to consultative examination panelists regarding protocols for consultative examinations and ancillary tests, as well as guidance to other DDS components to address and resolve issues related to procured medical services.

Assists in the development of intra-agency policies and procedures related to consultative examinations, laboratory tests, and ancillary studies including high-risk procedures.

Monitors ongoing performance of consultative examination and consultative
study providers and makes recommendations for quality improvement. Knowledge Skills Abilities:
Extensive knowledge of medical terminology, reporting requirements including examination specialities, laboratory procedures and ancillary test equipment.

Knowledge of rules, regulations, policies, and procedures in interpreting and applying complex medical policy or regulations related to medical testing protocols.

Knowledge of personal computer applications including databases, spreadsheets, word processing software, and case tracking programs.

Skill in the use of office equipment, including a personal computer and associated software, facsimile machines, voicemail systems, photocopiers, and printers.

Skill in organizing, prioritizing, and completing tasks, duties, and other work assignments in a timely and independent manner.

Skill in creating and administering record keeping systems.

Skill in communicating effectively, both verbally and in writing.

Ability to interpret complex policies and procedures.

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