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Utilization Review Nurse II
2 months ago
Nurse II
Under the direct supervision of the Utilization Review Nurse Manager, the Utilization Review (UR) Nurse is responsible for the assessment and evaluation of individual health records, service plans, and patient documentation related to Medicaid services for the elderly and individuals with intellectual and developmental disabilities (IDD). This role involves conducting face-to-face interviews with participants in various community service programs to assess the justification for services provided.
Utilizing both in-person assessments and comprehensive desk reviews, the UR Nurse applies clinical knowledge and nursing expertise to determine the appropriateness and quality of services, evaluate cost-effectiveness, validate health service needs, and authorize necessary services.
The UR Nurse also engages in quality assurance reviews and improvement initiatives, ensuring compliance with Medicaid program standards and state regulations.
This position collaborates with fellow UR nurses and regional staff to foster an effective statewide UR program, ensuring consistent application of UR policies and procedures.
Working under the general supervision of the UR Nurse Manager, this role allows for moderate independence and initiative in decision-making.
Essential Job Functions:Nurse II.
Regular attendance is required in accordance with agency policies, and additional duties may be assigned as necessary.
Conducts thorough desk reviews of documentation for Health and Human Services Commission (HHSC) and Medicaid Long Term Care Waiver Programs.
Participates in onsite evaluations of individuals selected in random samples.Reviews and documents services provided to elderly and disabled individuals, validating service needs and assessing the appropriateness, quality, and cost-effectiveness of those services.
(35%)Makes informed service authorization decisions on complex cases. (20%)
Conducts quality assurance reviews and compliance evaluations with Medicaid service requirements and state regulations. (15%)
Collaborates with other UR nurses through regular meetings to ensure effective implementation of the statewide UR program and adherence to policies. (10%)
Develops and provides resources and technical support to regional staff and service providers. (10%)
Acts as a Subject Matter Expert (SME) in Medicaid hearings regarding service reductions or denials. (5%)
Generates routine and specialized reports for program analysis. (5%)
Knowledge, Skills, and Abilities:
A minimum of one year of experience providing direct services to individuals with intellectual disabilities is required.
Comprehensive knowledge of healthcare laws, standards, regulations, medical procedures, community health principles, and Medicaid waiver program guidelines is essential.
Strong written and verbal communication skills are necessary for effective consultation, teaching, and report generation.Ability to:
interpret and explain relevant health laws and regulations; identify patterns of medical necessity, fraud, and abuse; proficiently use office software and technology; and travel as required.
A valid Texas Driving License is necessary, with the ability to travel frequently as needed.
