Managed Care Nurse Analyst

Brief Job Description:

The Nurse III, Managed Care Nurse Analyst, is a senior level position that reports to an Acute Care Utilization Review Unit’s (ACUR) Managed Care Clinical Review Manager.

If you are looking for an opportunity to use both considerable clinical experience and highly developed research and critical thinking skills, this job may be perfect for you.

This position is ideal for a registered nurse who wants to work with a team of highly advanced professionals to ensure Texas Medicaid recipients have appropriate access and coordination of medically necessary services through contracted managed care organizations (MCO) in the STAR, STAR+PLUS, STAR Kids, and STAR Health programs.

This position performs complex assessment and analysis of Medicaid MCO utilization management policies and procedures and clinical case files to determine compliance with Texas Medicaid contracts and state and federal regulations.

The Managed Care Nurse Analyst must demonstrate an ability to work as an effective team member within ACUR and with other divisions within HHSC, be proactive in seeking input from other staff in the Medicaid/CHIP Division, and work with varying types of medical professionals.

Activities include desk reviews of utilization management documents, analysis of contract compliance, various forms of communication with MCO staff and leadership through email, conference calls, webinars, and onsite reviews at multiple MCOs across the state.

MCO onsite reviews include overnight travel and case discussion with MCO leadership.

Essential Job Functions (EJFs):

All essential job functions ensure compliance and knowledge of Texas Medicaid MCOs utilization management with HHSC contracts and state and federal regulations related to STAR Kids, STAR, STAR+PLUS, and STAR Health programs:

·       Reviews clinical documentation, Medicaid MCO policies and procedures, and authorization criteria. 25%

·       Participates effectively in discussions of case, policy and procedure reviews with MCO leadership and staff. Conducts interviews with utilization management staff members during onsite reviews. 15%

·       Provides effective post-review follow-up by actively compiling findings and monitoring MCO activities related to non-compliance. 15%

·       Demonstrates competency in internal processes and usage of ACUR clinical and utilization management review tools to ensure accurate and consistent findings. 15%

·       Provides clinical review of complaints and inquiries by analysis of clinical documentation. Prepares written report of findings. 10%

·       Accurately interprets complex state and federal laws, regulations, and rules related to Texas Medicaid Managed Care during review activities. 10%

·       Provides consultation as a utilization management subject matter expert for the various activities to include contract procurement activities throughout the lifecycle of Texas Medicaid managed care contracts; training and guidance to internal and external staff, informs and collaborates with internal divisions regarding outcomes. 10%

Knowledge, Skills, Abilities (KSAs):

Knowledge of Texas Medicaid policy related to clinical services as detailed in the Texas Medicaid Provider Procedures Manual (TMPPM). Experience with utilization review in authorization of clinical services; case management; managed care utilization review principles and practices.

Knowledge of Health and Human Service Commission programs including Medicaid/CHIP. Knowledge of quality improvement principles.

Familiarity with ICD-10 and HCPCS/CPT codes.  

Skilled in establishing and maintaining effective working relationships with managers, coworkers, and other staff or program stakeholders.

Excellent computer skills, including Microsoft Office Suite.

Ability to present orally and in writing to a professional group. Demonstrated ability to work independently and function effectively as a member of a team, and under tight deadlines with high volume workloads.

Highly organized, and the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.

Detail and task oriented.

Highly proficient in the English language with excellent written, verbal, and interpersonal communication and presentation skills. Ability to actively participate in meetings and workgroups.

Registrations, Licensure Requirements or Certifications:

Must possess a current, unencumbered Texas Registered Nurse license (or a state that recognizes reciprocity through the Nurse Licensure Compact) in good standing.  

Initial Screening Criteria:

Bachelor's degree in nursing preferred.

Minimum three years nursing experience in a clinical setting required.

Experience with at least one of the following: Texas Medicaid, managed care, utilization review experience in authorization of clinical services, or case management.

Additional Information:

Telework opportunities are available for the position. The work location in Texas is flexible and is not limited to Austin and the cities listed in the posting.

Telework opportunities available following successful completion of initial orientation period or in accordance with business needs.