Nurse III

6 days ago

Austin, Texas, United States Texas Department of Aging & Disability Services Full time
Job Summary:

The Texas Department of Aging & Disability Services is seeking a highly skilled Nurse III to serve as a Managed Care Clinical Review Manager. This senior-level position requires a registered nurse with considerable clinical experience and highly developed research and critical thinking skills.

Key Responsibilities:
  • Perform complex assessment and analysis of Medicaid MCO utilization management policies and procedures to ensure compliance with Texas Medicaid contracts and state and federal regulations.
  • Conduct desk reviews of utilization management documents, analyze contract compliance, and communicate with MCO staff and leadership through various channels.
  • Participate in discussions of case, policy, and procedure reviews with MCO leadership and staff, and conduct interviews with utilization management staff members during onsite reviews.
  • Provide effective post-review follow-up by actively compiling findings and monitoring MCO activities related to non-compliance.
  • Accurately interpret complex state and federal laws, regulations, and rules related to Texas Medicaid Managed Care during review activities.
Requirements:
  • Knowledge of Texas Medicaid policy related to clinical services as detailed in the Texas Medicaid Provider Procedures Manual (TMPPM).
  • Experience with utilization review in authorization of clinical services, case management, and managed care utilization review principles and practices.
  • Knowledge of Health and Human Service Commission programs, including Medicaid/CHIP.
  • Excellent computer skills, including Microsoft Office Suite.
  • Ability to present orally and in writing to a professional group.
Preferred Qualifications:
  • Demonstrated ability to work independently and function effectively as a member of a team, and under tight deadlines with high volume workloads.
  • Highly organized, with the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.
  • Detail and task oriented, with highly proficient English language skills and excellent written, verbal, and interpersonal communication and presentation skills.
Working Conditions:

This position may require overnight travel and case discussion with MCO leadership.

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