Job Information
HEALTH AND HUMAN SERVICES COMMISSION Nurse IV in Austin, Texas
Job/Position DescriptionThe Nurse IV performs senior-level clinical review and consultative work for the Surveillance Utilization Review (SUR) division within the Office of Inspector General. Work conducted by this position includes performing retrospective utilization reviews and developing summaries of findings for multiple provider types within the Texas Medicaid program. This position serves as a resource and assists in developing guidelines to promote compliance with health-related laws, rules and regulations pertinent to fraud, waste and/or abuse in the Texas Medicaid program. Essential Job Functions(80%) Conducts retrospective utilization reviews and other senior-level consultative nursing work in support of the OIG SUR division and other divisions across OIG. Responsibilities include training, collaboration, ad-hoc assignments, medical record/document review, and tracking for post-review activities. Participates in medical record review and analysis process, summarizing feedback and findings to fulfill the OIG mission in identification of fraud, waste, and abuse. Responds to inquiries from OIG staff, leadership, providers, and legislative entities on the reviews and appeals process. Consults with appropriate internal and external stakeholders for policy and inquiries as needed. Monitors work product for accuracy and timeliness and provides training for process improvement.(5%) Reviews and provides feedback for the work of others within the OIG SUR division, including records reviews across various teams. Assists teams across SUR with data analysis and interpretation.(15%) Works under limited supervision with considerable latitude in professional judgment. Reviews internal policies for compliance with federal and state regulations and recommends policy and procedure updates. Incorporates recommendations and updates in trainings including any managed care or fraud initiatives.(5%) Participates in strategic planning for maintenance, development, and enhancements of case management, case processing, and case tracking systems for OIG SUR. Collaborates with team to identify and implement process improvements.(5%) Represents OIG SUR internally and externally at meetings and other forums. Coordinates responses for external stakeholders and audits with director, manager, and team with written or verbal feedback to address accuracy and consistency with program policy and procedure. Keeps manager informed as required or as necessary. Actively works to maintain Subject Matter Expert (SME) status through attendance at meetings and maintaining professional certifications. Registrations, Licensure Requirements or CertificationsLicensed as a Registered Nurse in the state of Texas or in a state recognized under the Compact Licensure Agreement. For those positions reviewing outpatient records, applicant must be a Certified Professional Coder (CPC) or be willing to obtain certification within one (1) year of start date. Knowledge Skills AbilitiesKnowledge of federal and state laws governing Medicaid policies and procedures. Knowledge that is achieved from experience working in managed care, healthcare, and/or health care billing environment, contract requirements, coding and billing requirements for reimbursement. Knowledge of nursing practices and procedures, medical diagnosis procedures and accepted medical treatment patterns. Knowledge of or ability to apply methods of analysis, detection, and measurement to identify potential fraud, waste, or abuse. Knowledge of e https://jobshrportal.hhsc.state.tx.us/ENG/CareerPortal/job_profile.cfm?szOrderID=599497 Copy the URL in the preceding sentence to an Internet Explorer browser to apply to the job directly through the Texas Health and Human Services Career Portal.