Managed Care Utilization Review Nurse

Managed Care Utilization Review Nurse Date: Nov 10, 2025 Location: FORT WORTH, TX – 1501 Circle Dr. Other potential locations: Arlington; Bedford; Cleburne; Katy; Watauga; Weatherford. Agency: Health & Human Services Commission (HHSC)Department: UR LTSS FTE Random Mmt StudyPosting Number: 11149Closing Date: 11/24/2025Posting Audience: Internal and ExternalOccupational Category: Healthcare Practitioners and TechnicalSalary Group: TEXAS-B-24Salary Range: $5,425.33 - $8,886.16Pay Frequency: MonthlyShift: DayAdditional Shift: Days (First)Telework: Eligible for TeleworkTravel: Up to 75%Regular/Temporary: RegularFull Time/Part Time: Full timeFLSA Exempt/Non-Exempt: ExemptMOS Codes: 290X, 46AX, 46FX, 46NX, 46PX, 46SX, 46YX, 66B, 66C, 66E, 66F, 66G, 66H, 66N, 66P, 66R, 66S, 66T, 66W Functional Title Managed Care Utilization Review Nurse Job Title Nurse III Job Description Nurse III Under the direct supervision of the UR nurse supervisor, the UR Nurse III conducts reviews of assessments, individual service plans (ISPs) and other relevant documentation to evaluate long term services and supports (LTSS) in Medicaid managed care and to determine compliance with policies, procedures, rules, laws, contract standards, and correctness of needs assessments for Medicaid managed care LTSS. The UR nurse uses an array of evaluation methods, including review of records and face‑to‑face interviews with waiver members for validation of service needs and service delivery. The UR nurse uses program knowledge and nursing expertise to determine service needs and quality. This position has moderate latitude for use of initiative and independent nursing judgment in the required evaluations. The UR nurse III will be responsible for complex policy interpretations, validation of, or recommendations for clinical review decisions made by Medicaid managed care organizations (MCOs) and provider agencies. This position will also be responsible for timely and accurate reporting. The UR Nurse III will also be responsible for working collaboratively with MCOs and providers to ensure coinciding and/or mutually dependent functions are accomplished smoothly. Essential Job Functions Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Implements UR activities. Reviews MCO policies and procedures, nursing activities, medical records, assessments including medical necessity/level of care (MN/LOC), and ISPs, to determine compliance with policies and procedures, correctness of assessments, standards of care, and quality of service. Makes recommendations for improvement as a result of the reviews. Produces routine and specialized data and information for program reports. (40%) Responsible for timely and accurate reporting of program activities. (20%) Informs and collaborates with internal divisions as necessary on program outcomes. (15%) Interprets complex state and federal laws, regulations, and rules related to the program. (10%) Performs other duties as assigned. (15%) Registrations, Licensure Requirements Or Certifications State of Texas Registered Nurse license in good standing. Knowledge, Skills, Abilities Knowledge of 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 organizing work; care and treatment of patients; written and verbal communication necessary to organize, develop, and review unit policies, rules, and guidelines; and to consult, teach, and provide clear and concise directions and reports. Ability to 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; gather, assemble, correlate, and analyze facts; devise solutions to problems; develop and evaluate policies and procedures; and prepare reports. Initial Screening Criteria Experience in nursing work. Graduation from an accredited four‑year college or university with major coursework in nursing (BSN or MSN preferred), or from an accredited nursing program. Experience in program evaluation, Utilization Review, and Long‑Term Services and Supports (LTSS) is preferred. Experience in pediatrics, adult and geriatric health preferred. Managed Care experience preferred. Additional Information Location based on office availability and applicant preference. This position can telework after successful completion of initial orientation period or in accordance with business needs. Military, Veteran, and ADA Information Active‑Duty, Military, Reservists, Guardsmen, and Veterans: Military occupations that relate to the initial selection criteria and registration or licensure requirements for this position may include, but are not limited to those listed in this posting. All are encouraged to apply if qualified. ADA Accommodations: In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the online application, contact the HHS Employee Service Center at 1‑888‑894‑4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview. Pre‑Employment Checks And Work Eligibility Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks. HHSC uses E‑Verify. You must bring your I‑9 documentation with you on your first day of work. Download the I‑9 Form. Telework Disclaimer This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs. Nearest Major Market Fort Worth Nearest Secondary Market Dallas #J-18808-Ljbffr