Nurse II
1 month ago
Nurse II
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 Services and Supports (CLASS), Deaf Blind and Multiple Disabilities (DBMD), Home and Community-Based Services (HCS), and Texas Home Living (TxHmL) programs to determine service justification. Based on the face to face 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, validate determinations of health service needs, and make service authorization decisions.
The UR nurse conducts a variety of quality assurance reviews, and quality improvement studies. The UR nurse will evaluate 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 reviews 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, determine 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. (15%)
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%)
Knowledge Skills Abilities:
Must have one year’s experience in the provision of direct services to persons with an intellectual disability. 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; Medicaid waiver program standards, policies, and procedures and government regulations and oversight mechanisms. 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. Must have a valid Texas Driving License and able to travel 75% of the time.
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