QA Nurse Manager

1 month ago

Austin, United States Texas Department of Aging & Disability Services Full time
Job Description:
Under the general supervision of the High Needs/Quality Assurance Director, the Quality Assurance (QA) Nurse Manager is responsible for managing the effective and efficient reviews conducted by the QA Nurses. Core functions of the QA Nurses include routine case reading functions and analysis to assess the accuracy of the MCO performance outcomes from the Managed Care Utilization Reviews. This involves examining and reviewing UR outcomes to determine compliance with program regulations, internal policies and procedures, state and federal statutes, identifying inaccuracies, and correcting such inaccuracies.
The QA Nurse Manager ensures consistent and accurate review of UR oversight of MCO performance. This position plans, assigns, and manages the work of the QA nurses. The UR Nurse Manager works under limited supervision, with considerable latitude for use of initiative and independent nursing judgment in the oversight of UR nursing activities for the Quality Assurance unit.
Essential Job Functions:
Attends work on a regular and predictable schedule in accordance with agency leave policy.

Oversees, guides, and evaluates utilization review and quality assurance activities in the development of UR strategies, program protocols, review procedures and tools to ensure Medicaid and CHIP managed care programs are delivered efficiently and effectively and are in compliance with federal and state laws, regulations, policies, and HHSC contracts and guidance. Ensures all Managed Care Utilization Reviews are conducted, recorded and reported correctly. 40%

Manages a business unit with functions including planning, and assigning work to unit staff, and providing leadership in the development, coordination, and evaluation of program activities and working closely with MCUR Operations and UR Review teams and other agency departments to accomplish goals. Hires and develops professional nursing and non-nursing staff and holds them accountable for achieving performance expectations and program goals. 35%

Oversees the analysis of data from reporting outcomes and identifies internal data errors and provides feedback to OMD/UR management for process improvements in the UR review, quality assurance activities and data collection process. Also works with cross divisional staff in development of training and providing technical assistance for staff to address the data errors. 20%

Other duties as assigned including creation and presentation of materials, information, and review findings to internal and external stakeholders. Develops and implements techniques for evaluating program activities, and reports findings and recommendations for improvements to management 5%
Knowledge Skills Abilities:
Knowledge of: Management principles; managed care laws; nursing techniques and procedures; health care laws, rules, standards, and regulations; medical diagnoses and procedures; accepted medical treatment programs; community health and nursing care principles, practices and procedures; Medicaid and managed care regulations and procedures; utilization management and review principles and practices; and health care needs and services for the aged and disabled as well as pediatric special needs.

Skill in: written and verbal communication; managing and motivating staff; development and maintenance of unit policies, rules, and guidelines; using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems; consulting, teaching, and providing clear and concise direction; and developing reports resulting from complex data analysis
Ability to: manage department activities; to establish goals and objectives; to devise solutions to administrative problems; to communicate effectively identify appropriate nursing care and other health care services; prepare, maintain, and present reports; explain and interpret applicable health laws, rules, standards, and regulations; organize, coordinate and evaluate nursing activities and delivery of public health services; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, fax machine and copier, telephone conferencing functions, and components of the Microsoft Office suite and Outlook e-mail; travel independently throughout the state as necessary. Ability to gather, assemble, correlate, and analyze facts; to devise solutions to problems; to develop and evaluate policies and procedures; and to prepare reports.

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