Quality Assurance 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.

Brief Job Description:

Under the general supervision of the UR Nurse Manager, the QA Nurse is responsible for quality assurance activities including but not limited to routine case reading functions and analysis to assess the accuracy of the MCO performance outcomes from the Long Term Supports and Services Utilization Reviews. This involves examining and reviewing UR outcomes to determine compliance with program regulations, internal policies and procedures, state, and federal statutes, identifying inaccuracies, and correcting such inaccuracies. Work involves assisting with planning, developing, and implementing corrective action measures and providing consultative services and technical assistance to program staff.
 
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.

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, STAR Kids, STAR+PLUS, and STAR Health programs:

Conducts case reading functions to ensure consistent execution of business processes and identify areas in need of change and analysis to assess the accuracy of data gathered by LTSS staff.  Reviews MCO policies and procedures, nursing activities, medical records, and evaluation of medical necessity, to determine compliance with state and federal laws, regulations, and rules related to the program, standards of care, and quality of service. 60%

Collaborates with staff to correct data with errors and provides feedback to the UR Nurse Manager and LTSS leadership pertaining to staff competencies in utilization of review tools and application of LTSS policies and procedures and makes recommendations for process improvements. 20%

Works with the UR Nurse Manager and LTSS leadership to develop and implement UR quality review activities, including ensuring inter-rater reliability and revisions to program protocols, policies, and tools. 20%

Knowledge, Skills and Abilities (KSAs):

Knowledge of: Texas Medicaid managed care policy and clinical services as detailed in HHSC contracts, waiver handbooks, and state and federal regulations. Knowledge of quality assurance and improvement measures and principles. Knowledge of Health and Human Service Commission programs including Medicaid/CHIP, STAR Plus HCBS, STAR Kids and STAR Health MDCP. Familiarity with ICD-10 and HCPC/CPT codes. 

Skill in: Experience with utilization review; case management; managed care utilization review principles and practices. Excellent computer skills, including Microsoft Office Suite. Skilled in establishing and maintaining effective working relationships with managers, coworkers, and other staff or program stakeholders.

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 and experience analyzing collected data. Highly proficient in the English language with excellent written, verbal, and interpersonal communication and presentation skills. Ability to actively participate in meetings and work groups.

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). Bachelor's degree in nursing preferred.

Initial Screening Criteria:

Minimum three years nursing experience in a clinical setting required.
Experience with at least one of the following: Texas Medicaid, managed care, or utilization review experience working with Medicaid waiver programs. 

Additional Information:

Information on application must clearly state how applicant meets the initial selection criteria in the Summary of Experience section of the application.

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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

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.