Nurse Reviewer

Job Title: Nurse III – Nurse Reviewer Location: Austin, TX – 4601 W Guadalupe St, Austin, TX Functional Title: Nurse Reviewer Agency: Health & Human Services Commission (HHSC) Department: Med Svcs-Quality Review TK Posting Number: 16324 Salary: $5,833.33 – $6,666.67 per month (Monthly) Shift: Day; First Days available Telework: Eligible Travel: Up to 10% Employment Type: Regular, Full time, Exempt Job Description The nurse reviewer (NR) works under the direction of the Surveillance Utilization Review (SUR) Regional Director and Regional Managers for the Office of Inspector General. The NR uses technical skills, analytical skills, and clinical expertise to perform highly complex senior‑level reviews of hospital and nursing facility records to ensure adherence to Texas Medicaid requirements and state and federal law. The NR works under limited supervision with considerable latitude for initiative and independent judgment. The NR reviews hospital records to validate medical necessity, accurate diagnoses and procedure codes by examining care plans, medical records, and patient assessments to verify adherence to medical coding guidelines and the consistency of quality care in hospitals and nursing facilities. The NR reviews nursing facility records to evaluate whether facilities correctly assessed and documented resident needs based on a review of minimum data set (MDS) assessments and medical record documentation. The NR performs other duties as assigned and required to maintain unit operations. Traveling approximately 10% of the time, with some overnight stays. Key Responsibilities (40%) Conduct ongoing retrospective reviews of nursing facility records to determine whether facilities correctly assessed residents’ needs, reimbursements were appropriate, and care was medically necessary. Meet established performance metrics; apply advanced nursing knowledge; identify potential fraud, waste, and abuse; maintain confidentiality and HIPAA privacy. (40%) Conduct ongoing retrospective reviews of hospital records to determine necessity of admission and the accuracy of diagnosis and procedural coding using federal coding guidelines. Meet performance metrics; apply advanced nursing knowledge; identify potential fraud, waste, and abuse; maintain confidentiality and HIPAA privacy. (15%) Interact professionally with Texas Medicaid providers, external stakeholders, and OIG colleagues. Follow policies, procedures, guidance, and direction when conducting reviews. Work under limited supervision with latitude in professional judgment. (5%) Support investigations and other OIG divisions in examining alleged violations of laws, rules, and regulations in Texas Medicaid. Licensure Requirements and Certifications Licensed to practice as a Registered Nurse in Texas or a state recognized under the Compact Licensure Agreement. License must be current and in good standing. Must be RAC‑CT (Resident Assessment Coordinator) certified or be willing to obtain certification within six months of start date. Initial Screening Criteria Graduation from an accredited school of professional nursing, college, or university. Experience using a personal computer and Microsoft software in a telework/remote environment. Minimum of two (2) years of experience in a program or service area related to hospital, nursing facility, acute care, and/or managed care. Full‑time experience in nursing facility administration and/or utilization review is preferred. Experience with Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) is preferred. Benefits Full‑time eligible employees receive 100% paid employee health insurance, a defined benefit pension plan, generous time‑off benefits, numerous career advancement opportunities, and other comprehensive benefits. Equal Employment Opportunity Discrimination based on race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic is prohibited. ADA Accommodation 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. #J-18808-Ljbffr