Nurse III

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our 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. Explore more details on the Benefits of Working at HHS webpage.

Job Description:

Nurse III performs clinical review and consultative work for the Surveillance Utilization Review (SUR) division within the Office of Inspector General (OIG). Work conducted in 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:

(60%) Conducts retrospective utilization reviews and other consultative nursing work supporting the OIG SUR division and other divisions across the OIG. Responsibilities include collaboration, medical record/document review, tracking for post-review activities, case/provider research, running queries, and other ad-hoc assignments. Participates in medical record review and analysis process, summarizing feedback and findings to fulfill the OIG mission of identifying 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 products for accuracy and timeliness.

(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.

(15%) Collaborates with others within the OIG/SUR division on work in the SUR division, providing input and assisting teams with data analysis and interpretation.

(5%) Represents the OIG in both internal and external meetings and forums. Coordinates responses for external stakeholders and audits in collaboration with the director, manager, and team, providing written or verbal feedback to ensure accuracy and consistency with program policies and procedures. Prepares and delivers reporting/status updates to management. Works with the team to identify and implement process improvements.

(5%) Performs related work as assigned. Keeps manager informed as required or as necessary.
 

Registrations, Licensure Requirements or Certifications:

Licensed to practice as a Registered Nurse in the State of Texas or in a state recognized under the Compact Licensure Agreement.
License is current and in good standing.

Knowledge Skills Abilities:

Knowledge of federal and state laws governing Medicaid policies and procedures.
Knowledge that is achieved from experience working in managed care, healthcare, and/or healthcare 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 evidence-based guidelines and application to medical services.
Ability to interpret and apply policies, procedures, regulations, and other healthcare criteria.
Ability to develop, revise, and apply policies, procedures, and regulations.
Ability to use personal computers and related software to create concise reports.

Ability to work effectively in a hybrid or remote work environment.
Ability to manage multiple program activities and priorities in meeting team metrics.
Able to work in a team environment across divisions and agencies.
Skill in managing conflicting priorities without jeopardizing deadlines.
Skill in communicating effectively in both written and oral communication.
Skill providing education, training, and feedback including presentations for both internal and external audiences.

Initial Screening Criteria:

Graduate of a college, university, or school of nursing.
Minimum of 2 years of experience in a program or service area related to hospital, nursing facility, acute care, and/or managed care.

Experience using a personal computer and software such as Word and Excel

Additional Information:

**This position may be located at any OIG location in the State in a hybrid work environment with a potential of 15% travel**

The OIG is responsible for preventing, detecting, auditing, inspecting, reviewing, and investigating fraud, waste, and abuse in the provision of HHS in Medicaid and other HHS programs. Potential OIG employees are subject to criminal background checks in accordance with the HHS Human Resources policy. Selected applicants must complete a national fingerprint-based criminal background check through the Texas Department of Public Safety (TDPS) and Federal Bureau of Investigations (FBI) to determine if they have criminal history record information that constitutes a bar to employment.

OIG will request that all applicants considered for an interview provide responses to in-basket questions. Failure to respond to the request could disqualify an applicant from the interview process.

Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of the HHSC Human Resources Manual.

HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

In compliance with the Americans with Disabilities Act (ADA), HHS 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.

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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