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Advanced Nurse Analyst for Managed Care
2 months ago
Position: Nurse III
Telework: Flexible work arrangements are available for this role.
The Nurse III, serving as a Managed Care Nurse Analyst, holds a pivotal senior position reporting to the Managed Care Clinical Review Manager within the Acute Care Utilization Review Unit (ACUR).
This role is tailored for a registered nurse eager to leverage extensive clinical expertise alongside advanced research and analytical skills.
The ideal candidate 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) across various programs.
Responsibilities include conducting 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 ACUR and engage proactively with other divisions, seeking input from colleagues in the Medicaid/CHIP Division and collaborating with diverse medical professionals.
Key activities encompass reviewing utilization management documents, analyzing compliance with contracts, and engaging in various forms of communication with MCO staff and leadership through digital correspondence, conference calls, webinars, and onsite evaluations.
Onsite Reviews: These may involve overnight travel and discussions with MCO leadership.
Core Responsibilities:
All essential functions ensure compliance with Texas Medicaid MCOs utilization management in accordance with HHSC contracts and applicable state and federal regulations:
- Review clinical documentation, MCO policies, and authorization criteria. 25%
- Engage in discussions regarding case and policy reviews with MCO leadership and staff, conducting interviews during onsite evaluations. 15%
- Provide thorough post-review follow-up by compiling findings and monitoring MCO activities related to compliance. 15%
- Demonstrate proficiency in internal processes and utilize ACUR clinical and utilization management review tools for 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%
- Act as a subject matter expert in utilization management, providing consultation throughout the lifecycle of Texas Medicaid managed care contracts, including training and guidance for internal and external staff.
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 for clinical service authorization, case management, and managed care principles. Familiarity with Health and Human Service Commission programs, including Medicaid/CHIP, is essential.
Proficient computer skills, particularly in Microsoft Office Suite, are required. Strong oral and written communication skills are necessary for effective presentations to professional groups.
The ability to work independently while being an effective team member under tight deadlines and high-volume workloads is crucial. Candidates should be highly organized, capable of managing multiple projects in a fast-paced environment, and detail-oriented.
Proficiency in the English language, along with excellent written, verbal, and interpersonal communication skills, is expected. The ability to actively participate in meetings and workgroups while establishing effective working relationships with managers, coworkers, and stakeholders is vital.
Knowledge of quality improvement principles and familiarity with ICD-10 and HCPC/CPT codes will be advantageous.
