Nurse IV
3 weeks ago
The Nurse IV performs senior-level clinical review and consultative work for the Surveillance Utilization Review (SUR) division within the Office of Inspector General. Work conducted by this position includes performing retrospective utilization reviews and developing summaries of findings for multiple provider types within the Texas Medicaid program. This position serves as a resource and assists in developing guidelines to promote compliance with health-related laws, rules and regulations pertinent to fraud, waste and/or abuse in the Texas Medicaid program. Essential Job Functions:
(80%) Conducts retrospective utilization reviews and other senior-level consultative nursing work in support of the OIG SUR division and other divisions across OIG. Responsibilities include training, collaboration, ad-hoc assignments, medical record/document review, and tracking for post-review activities. Participates in medical record review and analysis process, summarizing feedback and findings to fulfill the OIG mission in identification of fraud, waste, and abuse. Responds to inquiries from OIG staff, leadership, providers, and legislative entities on the reviews and appeals process. Consults with appropriate internal and external stakeholders for policy and inquiries as needed. Monitors work product for accuracy and timeliness and provides training for process improvement.
(5%) Reviews and provides feedback for the work of others within the OIG SUR division, including records reviews across various teams. Assists teams across SUR with data analysis and interpretation.
(15%) Works under limited supervision with considerable latitude in professional judgment. Reviews internal policies for compliance with federal and state regulations and recommends policy and procedure updates. Incorporates recommendations and updates in trainings including any managed care or fraud initiatives.
(5%) Participates in strategic planning for maintenance, development, and enhancements of case management, case processing, and case tracking systems for OIG SUR. Collaborates with team to identify and implement process improvements.
(5%) Represents OIG SUR internally and externally at meetings and other forums. Coordinates responses for external stakeholders and audits with director, manager, and team with written or verbal feedback to address accuracy and consistency with program policy and procedure. Keeps manager informed as required or as necessary. Actively works to maintain Subject Matter Expert (SME) status through attendance at meetings and maintaining professional certifications.
Knowledge Skills Abilities:
Knowledge of federal and state laws governing Medicaid policies and procedures.
Knowledge that is achieved from experience working in managed care, healthcare, and/or health care billing environment, contract requirements, coding and billing requirements for reimbursement.
Knowledge of nursing practices and procedures, medical diagnosis procedures and accepted medical treatment patterns.
Knowledge of or ability to apply methods of analysis, detection, and measurement to identify potential fraud, waste, or abuse.
Knowledge of evidence-based guidelines and application to medical services.
Ability to interpret and apply policies, procedures, regulations, and other healthcare criteria.
Ability to develop, revise and apply policies, procedures and regulations.
Ability to use personal computers and related software to create concise reports. Ability to work effectively in a hybrid or remote work environment.
Ability to manage multiple program activities and priorities in meeting team metrics.
Able to work in a team environment across divisions and agencies.
Skill managing conflicting priorities without jeopardizing deadlines.
Skill communicating effectively in both written and oral communication.
Skill providing education, training, and feedback including presentations for both internal and external audiences.
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