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Senior Utilization Review Nurse
2 months ago
Under the general oversight of the High Needs Quality Assurance Manager, the High Needs UR Nurse III plays a crucial role in assessing long-term services and supports (LTSS) for individuals with significant needs enrolled in various programs. These include STAR Kids, STAR+PLUS, Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS), and Deaf Blind with Multiple Disability (DBMD). The responsibilities encompass a thorough clinical review of medical documentation, assessments, planning documents, and other pertinent records to validate service requirements and delivery.
This position is ideal for those seeking to leverage extensive clinical expertise alongside advanced research and analytical skills.
Key Responsibilities:1. Conduct comprehensive reviews of high needs cases, focusing on individuals transitioning from STAR Kids, General Revenue (GR), and other assigned requests, emphasizing nursing interventions and service delivery. (30%)
2. Ensure compliance and provide oversight for nursing activities, including medical records and assessments, verifying medical necessity and level of care for accuracy. (15%)
3. Validate compliance with Medicaid service requirements and state regulations for individuals diagnosed with Intellectual and Developmental Disabilities (IDD), assessing service quality and cost-effectiveness. (15%)
4. Collaborate with colleagues through regular and ad hoc meetings to ensure consistent application of utilization review policies and procedures. (5%)
5. Develop and provide resources and technical assistance related to high needs transitions to agency staff, managed care organizations, and external stakeholders. (15%)
6. Serve as a subject matter expert in Medicaid fair hearings concerning appealed service reductions or denials for IDD high needs transition cases. (10%)
7. Research and respond to legislative inquiries regarding High Needs Cases. (5%)
8. Participate in special projects as requested. (5%)
Required Knowledge, Skills, and Abilities:
- Comprehensive understanding of Texas Medicaid policies related to clinical services and service delivery, as outlined in the Uniform Managed Care Contract Manual and other relevant Medicaid contracts.
- Experience in utilization review for clinical service authorization, case management, and managed care principles.
- Proficient in Microsoft Office Suite and excellent communication skills, both verbal and written.
- Ability to work independently and collaboratively within a team, managing multiple projects effectively in a fast-paced environment.
- Strong organizational skills with attention to detail and the capacity to handle competing priorities.
- Familiarity with quality assurance principles and knowledge of ICD-10 and HCPC/CPT coding.
