Clinical Utilization Review Nurse III
2 weeks ago
The position of Nurse III is available with opportunities for telecommuting. The work environment is adaptable and not confined to specific locations.
As a Senior Managed Care Nurse Analyst, you will play a pivotal role within the Acute Care Utilization Review Unit, reporting directly to the Managed Care Clinical Review Manager.
This role is tailored for a registered nurse eager to leverage extensive clinical expertise alongside advanced research and analytical skills.
You will collaborate with a team of skilled professionals to ensure that Texas Medicaid recipients receive appropriate access and coordination of essential medical services through contracted managed care organizations (MCO) in various programs.
Your responsibilities will include performing in-depth assessments and evaluations of Medicaid MCO utilization management policies and clinical case files to ensure adherence to Texas Medicaid contracts and relevant regulations.
The Managed Care Nurse Analyst is expected to be an effective team player within the Acute Care Utilization Review Unit and engage proactively with colleagues across the Health and Human Services Commission.
Key activities will involve conducting desk reviews of utilization management documents, analyzing compliance with contracts, and engaging in various forms of communication with MCO staff and leadership through virtual meetings and onsite evaluations.
Onsite evaluations may require travel and discussions with MCO leadership.
Key Responsibilities:
The essential functions of this role ensure compliance with Texas Medicaid MCOs utilization management standards and regulations:
- Review clinical documentation and MCO policies and procedures. 25%
- Engage in discussions regarding case reviews and policies with MCO leadership and staff. Conduct interviews during onsite evaluations. 15%
- Provide thorough follow-up by compiling findings and monitoring MCO activities related to compliance. 15%
- Demonstrate proficiency in internal processes and utilization management review tools to ensure accurate outcomes. 15%
- Conduct clinical reviews of complaints and inquiries, preparing detailed reports of findings. 10%
- Interpret complex state and federal regulations related to Texas Medicaid Managed Care during review processes. 10%
- Offer consultation as a subject matter expert in utilization management for various activities, including contract procurement and staff training.
10% Required Knowledge, Skills, and Abilities:
In-depth knowledge of Texas Medicaid policies regarding clinical services as outlined in the Texas Medicaid Provider Procedures Manual.
Experience in utilization review, case management, and managed care principles is essential. Proficiency in Microsoft Office Suite is required.The ability to communicate effectively, both orally and in writing, to professional audiences is crucial.
You should be capable of working independently while also thriving as part of a team, managing tight deadlines and high workloads efficiently.
Strong organizational skills and the ability to handle multiple projects in a fast-paced environment are necessary. Attention to detail and task orientation are vital. Excellent proficiency in English, along with strong interpersonal communication skills, is expected. The ability to actively participate in meetings and collaborate effectively with various stakeholders is essential. Familiarity with quality improvement principles and knowledge of ICD-10 and HCPC/CPT codes is advantageous.
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