Nurse Reviewer

Overview The Texas Health and Human Services Commission (HHSC) is hiring a Nurse Reviewer (Nurse III) to work under the Surveillance Utilization Review (SUR) Regional Director and Regional Managers in the Office of Inspector General. The role supports Texas Medicaid compliance through clinical reviews of hospital and nursing facility records. Responsibilities Conduct ongoing retrospective reviews of nursing facility records to verify appropriate assessment of resident needs, medical necessity of care, and Medicaid reimbursement; identify potential fraud, waste, and abuse. Review hospital records to validate medical necessity, accuracy of diagnosis and procedure coding, and adherence to federal coding guidelines; maintain confidentiality and HIPAA privacy standards. Interact professionally with Texas Medicaid providers, external stakeholders, and OIG colleagues; follow established policies, procedures, and guidance. Support investigations and other OIG divisions on alleged violations of Texas Medicaid laws, rules, and regulations. Licensure and Certifications Registered Nurse licensed in Texas or a state recognized under the Compact Licensure Agreement, license current and in good standing. Resident Assessment Coordinator (RAC‑CT) certification required, or willing to obtain certification within 6 months. Qualifications Graduation from an accredited nursing school. Minimum 2 years of experience in hospital or nursing facility utilization review, acute care, managed care, or related program/service area. Full‑time experience in nursing facility administration and/or utilization review preferred. Experience with Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) preferred. Proficiency using personal computer and Microsoft software in a remote/telework environment. Additional Information Travel of up to 10% of the time with occasional overnight stays. Telework is eligible but subject to agency policies. Background checks and criminal history verification are required. HHSC uses E‑Verify; bring I‑9 documentation on first day of work. EEO & ADA Statement HHSC is an equal opportunity employer that encourages all qualified individuals, including protected veterans, active‑duty personnel, and individuals with disabilities, to apply. HHSC will provide reasonable accommodations during the hiring and selection process for qualified applicants with a disability. #J-18808-Ljbffr