Utilization Review Nurse

TX-HHSC-DSHS-DFPS • Brenham, TX

2d

About The Position

The Medicaid Hospice Utilization Review Nurse reviews and evaluates medical records, assigned medical necessity documents, along with other documentation to support program eligibility and utilization of the Medicaid Hospice program. The Hospice UR nurse uses program knowledge of Medicaid program eligibility requirements and service requirements, state and federal rules, and agency policies. The UR nurse conducts desk reviews to validate eligibility, appropriateness of screening, active services and quality of care as reflected by the choice of services provided, type of staff utilized, and delivery/ implementation and documentation of services provided. The UR nurse participates in hearings, produces data and information for program quality assurance and improvement, provides resources, direction and technical assistance to HHSC employees, private and public stakeholders and other entities as directed. This position works under the general supervision of the Hospice Utilization Review Manager with latitude for initiative and independent judgment. Performs other duties as assigned.

Requirements

• Must be licensed as a professional nurse (RN)in good standing in the state of Texas or a state that recognizes Licensure Compact.
• Knowledge of nursing techniques and procedures; health care laws, rules, and standards; accepted medical treatment patterns and practices; community and nursing procedures; quality management, utilization management and review principles and practices for the elderly and disabled; Medicaid hospice program standards, policies and procedures and oversight mechanisms for services to the elderly and disabled.
• Ability to write in a clear, concise manner, using correct grammar and punctuation.
• Ability to make oralpresentations.
• Minimum 2 years in direct patient care.
• Experience conducting quality assurance or utilization review activities.

Nice To Haves

• Palliative care or end of life experience preferred.
• BSN or higher preferred.

Responsibilities

• Reviews physician narratives, medical records and other supporting documentation to determine program eligibility at the time of service delivery 20%.
• Reviews, evaluates, and documents Medicaid Hospice services provided to Medicaid eligible individuals 10%.
• Participates in quality assurance reviews and quality improvement studies and evaluates compliance with Medicaid Program requirements, state rules, regulations, policies and procedures 5%.
• Works collaboratively with various agency units and stakeholders 5%.
• Ensures UR policies and procedures are applied consistently 5%.
• Develops and provides resources to providers, respond internal and external correspondence, evaluate unit, policy or rule changes proposed, develop and maintain policy and procedure for UR reviews 5%.
• Work involves conducting in-depth analysis of paid service claims 10%
• Composing written responses to agency staff, providers, and advocates 10%
• Interpreting Texas Medicaid and state program rules, regulations, policies, and procedures 10%.
• Conducts research to resolve and track issues and problems 5%.
• Participate and facilitate in workgroups charged with developing and revising policy and operational changes and provide relevant program information to ensure that suggestions for developing and changing policy and operations are addressed 5%.
• Write summaries and reports 10%.
• Performs other duties as assigned. Attends work on a regular and predictable schedule.

Benefits

• comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed