Nurse II

3 weeks ago

Austin, United States Texas Department of Aging & Disability Services Full time
Job Description:
*Posted statewide*

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 providing oversight and monitoring of provider requirements with Individual Plans of Care (IPC), enhanced staffing rate requests for Individualized Skills and Socialization services, and Level of Care/Level of Need (LOC/LON) determinations.

The Nurse II position provides highly complex consultative and technical assistance, including research and assessment directly to management, HHSC program staff, local authority (LIDDA) staff, the Home and Community-based Services (HCS), Texas Home Living (TxHmL), and Intermediate Care Facility (ICF/ID) provider base, advocacy groups, stakeholders, program participants and their families.

The utilization review (UR) nurse reviews and evaluates program records, medical records, needs assessments, individual plans of care (IPCs), and other documentation related to proposed service plans for individuals enrolled in the Home and Community-based Services (HCS), Texas Home Living (TxHmL), and Intermediate Care Facility (ICF/ID) programs based on documentation received from program service planning teams. Based on these reviews and evaluation, the UR nurse uses program knowledge and clinical expertise to determine the appropriateness, quality, and cost effectiveness of each request and to assess and validate determinations of health needs and service provision for the purpose of making service authorization and levels of need decisions.

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.

Responsibility for this position includes the following: Routinely reviews and analyzes forms turned in for enhanced rates for Individualized Skills and Socialization services including reviewing documents to determine why an enhanced rate is needed and authorizing the rate for a short term or ongoing need. Analyzes Intellectual Disability/Related Condition (ID/RC) data to assess the need for additional oversight. Conducts desk reviews to determine compliance with HHSC rules, policies and procedures related to enrollments, IPCs and LOC/LONs. Conducts utilization review and evaluation of proposed IPCs and makes clinical authorization decisions regarding participant eligibility and plans of care. Evaluates IPC and eligibility activities and trends to resolve technical problems, identify opportunities for improvement and to make recommendations for improvements in utilization review processes. Conducts analysis of data and reports as assigned, and collects, organizes, analyzes and prepares materials in response to requests for program information, or special project reports. Develops and revises utilization review tools (e.g., review protocols, evaluation forms, etc.) in accordance with program objectives and goals. May serve as the lead to prioritize the work of colleagues by assigning provider deliverables to designated unit staff in absence of the unit supervisor. Serves as agency representative in Medicaid fair hearings. Conducts training and provides guidance to staff in the development or integration of new or revised operational procedures. Coordinates the review and evaluation of information on service delivery system methods, outputs, and activities in order to identify gaps in resources and recommend improvements. Coordinates and collaborates with program staff through participation in unit and cross-agency workgroups related to unit functions and planning to analyze, develop, and implement program initiatives.

Works under limited supervision with considerable latitude for the 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.

Routinely reviews and analyzes forms turned in for enhanced rates for Individualized Skills and Socialization services including reviewing documents to determine why an enhanced rate is needed and authorizing the rate for a short term or ongoing need. (10%)

Provides highly complex consultative and technical assistance, including research, assessment and planning directly to management, HHSC program staff, HHSC contract management staff, local authority (LA) staff, the program provider base, advocacy groups, stakeholders, program participants and their families. (20%)

Oversees and monitors provider requirements with Individual Plans of Care (IPC) and Level of Care/Level of Need (LOC/LON) determinations. (30%)

Conducts analysis of data and reports as assigned, and collects, organizes, analyzes and prepares materials in response to requests for program information, or special project reports. (10%)

Serves as agency representative in Medicaid fair hearings. (5%)

Develops and revises utilization review tools (e.g., review protocols, evaluation forms, etc.) in accordance with program objectives and goals. (5%)

Conducts training and provides guidance to staff in the development or integration of new or revised operational procedures. (5%)

Coordinates and collaborates with program staff through participation in unit, agency and cross-agency workgroups related to unit functions and planning to analyze, develop, and implement program initiatives. (5%)
Will serve as the lead to prioritize the work of colleagues by assigning provider deliverables to designated unit staff during the absence of the supervisor. (5%)

Works collaboratively across MCS to identify innovative and effective solutions for clients and staff. (5%) Knowledge Skills Abilities:
Must be a Registered Nurse with a valid RN license.

At least one year of experience working with individuals with intellectual/disabilities or related conditions.

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

Ability to communicate effectively, both orally and in writing.

Ability to gather, assemble, correlate, and analyze information; to devise solutions to problems; to prepare reports; to develop, evaluate, and interpret policies and procedures; to train, lead, and/or prioritize the work of others.

Ability to operate computers and experience using Microsoft Office products.

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