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Neonatal Nurse Practitioner
2 weeks ago
Weslaco, Texas, United States Pediatrix Medical Group Full timeJob SummaryPediatrix Medical Group is seeking a highly skilled Neonatal Nurse Practitioner to join our team of dedicated healthcare professionals. As a Neonatal Nurse Practitioner, you will provide high-quality, patient-centered care to critically ill newborns and their families.ResponsibilitiesProvide comprehensive care to neonates in a level II and III...
Nurse II
2 months ago
Under the direct supervision of the Utilization Review Nurse Manager, the Utilization Review Specialist will be responsible for reviewing and evaluating individual's records, individual service plans, patient assessments, and documentation related to Medicaid waiver programs. The Specialist will conduct face-to-face interviews with individuals enrolled in Medicaid waiver programs to determine service justification.
Key Responsibilities:- Conduct desk reviews of required documentation for Medicaid waiver programs.
- Participate in onsite reviews of individuals identified in the random sample.
- Review, evaluate, and document services provided to aged and disabled persons and persons with intellectual disability to validate service needs, service provision, determine appropriateness, quality, and cost effectiveness of services.
- Makes service authorization decisions on difficult, complicated, and/or targeted cases.
- Conduct a variety of quality assurance reviews and quality improvement studies and evaluates compliance with Medicaid program service requirements, state rules, regulations, policies, and procedures.
- Works collaboratively with other Utilization Review Specialists through routine and ad hoc meetings to implement an effective statewide Utilization Review program and to ensure Utilization Review policies and procedures are applied consistently.
- Develops, provides resources and technical assistance to regional staff and providers.
- Testifies as the Subject Matter Expert (SME) in Medicaid fair hearings related to appealed service reductions or denials.
- Produces routine and specialized data and information for program reports.
- Must have one year's experience in the provision of direct services to persons with an intellectual disability.
- Knowledge of nursing health care laws, rules, standards, and regulations, medical diagnoses and procedures, community health and nursing care principles, quality management, utilization management, health care needs and services for elderly and disabled, Medicaid waiver program standards, policies, and procedures and government regulations and oversight mechanisms.
- Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports.
- Ability to explain and interpret applicable health laws, rules, standards, and regulations; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, copier, Microsoft Office suite and Outlook e-mail; travel throughout the state as necessary.
- Must have a valid Texas Driving License and able to travel 75% of the time.
