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Senior Managed Care Nurse Analyst
2 months ago
Position: Nurse III
Telecommuting options are available for this role, allowing for flexible work arrangements.
The Nurse III, specializing as a Managed Care Nurse Analyst, is a senior-level role reporting to the Managed Care Clinical Review Manager within the Acute Care Utilization Review Unit.
This position is tailored for a registered nurse eager to leverage extensive clinical expertise alongside advanced research and analytical skills.
Ideal candidates will collaborate with a team of skilled professionals to guarantee that Texas Medicaid recipients receive appropriate access and coordination of essential medical services through contracted managed care organizations (MCO) within various programs.
Responsibilities include conducting thorough 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 must exhibit strong teamwork capabilities within the Acute Care Utilization Review Unit and effectively engage with diverse medical professionals.
Key activities involve reviewing utilization management documentation, analyzing compliance with contracts, and communicating with MCO staff and leadership through various channels.
Onsite evaluations of MCOs may require overnight travel and discussions with MCO leadership.
Core Responsibilities:
All core responsibilities focus on ensuring compliance with Texas Medicaid MCO utilization management and related regulations:
- Examine clinical documentation, MCO policies, and authorization criteria. 25%
- Engage in discussions regarding cases and policy reviews with MCO leadership and staff, including interviews during onsite evaluations. 15%
- Provide thorough follow-up post-review by compiling findings and monitoring MCO compliance activities. 15%
- Demonstrate proficiency in internal processes and utilization management review tools to ensure accurate findings. 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 activities. 10%
- Offer expert consultation on utilization management for various activities, including contract procurement and training for internal and external staff.
10% Required Knowledge, Skills, and Abilities:
In-depth knowledge of Texas Medicaid policies related to clinical services as outlined in the Texas Medicaid Provider Procedures Manual (TMPPM).
Experience in utilization review, case management, and managed care principles. Familiarity with Health and Human Services Commission programs, including Medicaid/CHIP. Proficient in computer applications, particularly Microsoft Office Suite.Strong oral and written communication skills for professional presentations.
Proven ability to work independently and collaboratively within a team, managing tight deadlines and high workloads. Highly organized with the capacity to manage multiple projects in a dynamic environment while prioritizing tasks effectively. Detail-oriented with excellent communication and interpersonal skills. Ability to actively participate in meetings and workgroups while fostering effective relationships with colleagues and stakeholders. Knowledge of quality improvement principles and familiarity with ICD-10 and HCPC/CPT coding.