Nurse II

Nurse III position plays a vital role in reviewing plans of care for individuals enrolled in Texas’ 1915 (c) waiver programs including CLASS, DBMD, HCS, TxHmL and Community Attendant Services (CAS). The primary responsibility is conducting utilization reviews (UR) to ensure people receive the appropriate type and amount of services based on their needs.  

 The UR Nurse uses a combination of desk reviews, in-person or virtual interviews, and clinical judgment to determine if services are appropriate, high quality, and cost-effective. Interview should be conducted in person whenever possible, but there is flexibility to conduct them via video or phone if needed. Through this process, the nurse validates service needs, health and safety concerns, and makes authorization decisions.  

 While utilization review is the primary focus, this position also includes responsibilities in quality assurance, targeted reviews, and occasionally Level of Need (LON) evaluation especially when there are overlapping clinical and non-clinical concerns. The Nurse III may act as a consultant on these more complex clinical issues. The Nurse III also: reviews the work of Nurse IIs for internal quality assurance, provides technical assistance, coaching, training to internal HHSC staff and external partner, including Local IDD Authorities (LIDDAs), Case Management Agencies (CMAs), and Direct Service Agencies (DSAs). Nurse III may serve as a Subject Matter Expert (SME) in Medicaid fair hearings when service reductions or denials are appealed, collaborates routinely with other UR nurses and field staff to ensure consistent application of UR policies and support a statewide utilization review program, and may help develop and share tools and resources with regional teams and providers.  

  The role requires the ability to work independently, exercise sound clinical judgment, and operate with moderate latitude under the general supervision of the Utilization Review Nurse Manager. A Nurse III must be licensed under the State of Texas or in a Nurse Licensure Compact state, have 2 years of experience as a RN, meet federal requirements of a Qualified Intellectual Disability Professional (QIDP) under 42 CFR 483.430(a), including 1 year of direct experience with persons with intellectual or developmental disabilities, and must hold a valid Texas driver’s license and willing to travel up to 75% of the time. 

 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 of required documentation for Health and Human Services Commission (HHSC), Medicaid Long Term Care Waiver Programs and Community Attendant Services (CAS). Participates in onsite reviews of the individuals identified in the random sample. Reviews, evaluates, and documents services provided to aged and disabled persons and persons with intellectual disability to validate service needs, service provision, determine appropriateness, quality, and cost effectiveness of services. (30%) 

Makes service authorization decisions on difficult, complicated, and/or targeted cases. (20%) 

Conducts a variety of quality assurance reviews and quality improvement studies and evaluates compliance with Medicaid program service requirements, state rules, regulations, policies, and procedures. Responsibilities include internal quality assurance of reviews completed by Nurse II’s and providing technical support, coaching and training to internal HHSC staff, individuals/LAR’s, and to external providers, Local Intellectual and Developmental Disability Authorities (LIDDAs), Case Management Agencies (CMAs), and Direct Services Agencies (DSAs).  (15%) 

Works collaboratively with other UR nurses through routine and ad hoc meetings to implement an effective statewide UR program and to ensure UR policies and procedures are applied consistently. (10%) 

Develops, provides resources and technical assistance to regional staff and providers. (10%) 

Testifies as the Subject Matter Expert (SME) in Medicaid fair hearings related to appealed service reductions or denials. (5%) 

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

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

 Knowledge, Skills and Abilities (KSAs): 

Meets the criteria for designation as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required.  

Knowledge of nursing health care laws, rules, standards, and regulations, medical diagnoses and procedures, community health and nursing care principles, quality management, utilization management, health care needs and services for elderly and disabled. 

Thorough knowledge of ID and other developmental disability related conditions, HCS, TxHmL, CLASS, DBMD, CAS, and ICF/ID program rules, service array and billing guidelines, local authority functions and waiver service system. 

Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports.  

Awareness of federal and state laws relating to long term care and other Medicaid and non-Medicaid services and programs. 

Knowledge of program planning, implementation and evaluation, and continuous quality improvement. 

Ability to communicate effectively, both orally and in writing. 

Ability to interpret statistical information. 

Ability to multi-task, handle stress and meet deadlines. 

Ability to work collaboratively across MCS to accomplish objectives. 

A keen attention to detail and the ability to implement creative solutions to problems. 

Able to balance team and individual responsibilities. 

Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports. 

Ability to: explain and interpret applicable health laws, rules, standards, and regulations; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, copier, Microsoft Office suite and Outlook e-mail; travel throughout the state as necessary. 

 Registrations, Licensure Requirements or Certifications: 

Must be licensed as a professional Registered Nurse (RN) in the state of Texas or a state that recognizes reciprocity through the Nurse Licensure Compact.   

Qualification as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required.   

Must have a valid Texas Driver License. 

 Initial Screening Criteria: 

Two-year experience working as a Registered Nurse (RN). 

  Graduation from an accredited four-year college or university with major course work in nursing preferred, or from an accredited nursing program. BSN preferred, experience and education may be substituted for one another. 

  Must meet the federal definition of a Qualified Intellectual and Developmental Disability Professional as defined in 42 Code of Federal Regulations 483.430(a). Must have at least one year of experience working directly with persons with intellectual disability or other developmental disabilities. 

  Must be able to travel 75% of the time. 

  Experience in utilization review, or quality assurance activities in long term services and supports for the aged and disabled.