Nurse III

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The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Nurse III. MCS is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by providing oversight and monitoring of provider requirements with Individual Plans of Care (IPC) determinations.

Under supervision of the Director of the IDD Waivers Utilization Review Unit, the utilization review (UR) nurse reviews and evaluates medical records, needs assessments, individual plans of care (IPCs), medical records, and other documentation related to proposed service plans for individuals enrolled in the Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disability (DBMD) and Intermediate Care Facility (ICF/IID) programs based on documentation received from program service planning teams. Based on these reviews and evaluation, the UR nurse uses program knowledge and nursing expertise to determine the appropriateness, quality, and cost effectiveness of each request and to assess and validate determinations of health needs and service provision for the purpose of making service authorization decisions.

The nurse makes service authorization decisions for program staff and providers on difficult, complicated, and/or targeted cases. This position evaluates documented service provision activities and makes recommendations based on these findings when applicable. The nurse also uses program knowledge to evaluate compliance with Medicaid program service requirements, state rules, regulations, policies, and procedures.

The ideal candidate thrives in an environment that emphasizes: teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.

The nurse will participate in Medicaid fair hearings, produce data and information for program reports, develop, provide resources, consultation, training, direction, and technical assistance to colleagues, the IDD waiver community provider base, advocacy groups, stakeholders, program participants and their families regarding nursing services/interventions/justifications. This position works collaboratively with clinical review staff in the unit and other nurses to ensure utilization review policies and procedures are applied consistently. The nurse position offers moderate latitude for use of initiative and independent judgment.  

Essential Job Functions (EJFs)

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Conducts desk reviews with a focus on nursing interventions, treatments as well as those individuals assessed to need a higher percentage of nursing due to their medically fragile or compromised medical condition when a referral to do so is received. (30%)

Reviews, evaluates, and documents Medicaid community services provided to persons with diagnoses of IDD to validate service needs and service provision, determine appropriateness, quality, and cost effectiveness of services. (20%)

Testifies as the subject matter expert in Medicaid fair hearings related to appealed service reductions or denials. (10%)

Evaluates compliance with Medicaid program service requirements, state rules, regulations, policies, and procedures. (5%)

Works collaboratively with colleagues through routine and ad hoc meetings to ensure utilization review policies and procedures are applied consistently. (5%)

Develops, provides resources and technical assistance to the IDD waiver community provider base, advocacy groups, stakeholders, program participants and their families. (5%)

Produces routine and specialized data and information for program reports. (5%)

Participates in agency workgroups as assigned to provide medical perspective related to waiver policy decisions. (5%)

Acts as liaison for individuals receiving services such as personal care services and private duty nursing as well as individuals seeking services through the STAR+PLUS waiver. (5%)
 

Researches and responds to legislative inquiries. (5%)

Works collaboratively across MCS to identify innovative and effective solutions for clients and staff. (5%)
 

​​​​​​​Registrations, Licensure Requirements or Certifications 

Must be a Registered Nurse with a valid RN license.
Qualification as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required  

Initial Screening Criteria

Must be a Registered Nurse with a valid RN license.

Be a QIDP with at least one years of experience working with individuals with intellectual/disabilities or related conditions.

​​​​​​​Knowledge, Skills and Abilities (KSAs)
Knowledge of ID and other developmental disability related conditions, HCS, TxHmL, CLASS, DBMD and ICF/ID program rules, service array and billing guidelines, local authority functions and waiver service system.
Ability to communicate effectively, both orally and in writing.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form