Healthcare Svcs Review Nurse

Salary: $32.84 - $60.18

Job Overview

Coordinate and perform quality monitoring of services that provide care to the indigent citizens of the County enrolled in the Hillsborough County Health Care Plan (HCHCP). Assist contracted providers (physicians, hospitals, ancillary providers/facilities) with quality assurance aspects of their care to enrolled clients. Maintain uniform protocols followed by all contracted providers to ensure appropriate care to clients. Represents the County as its clinical liaison for the Drug Review Committee and the BOCC established Medical Subcommittee to advise on clinical and utilization issues. Serves as a resource for the HCHCP. Conducts special projects relating to the HCHCP. Manages communications and cooperation amongst the four networks and the care they provide to our clients.

Ideal Candidate

The ideal candidate will have five years' experience performing quality assurance, utilization review and clinical case management duties. Knowledge of Federal, State and community resources within Hillsborough County is preferred. The ideal candidate will be bilingual in English and Spanish and have at least three years experience working with Excel and Word. Experience working for a payor/insurance provider is desired.

Core Competencies

• Customer Commitment - Proactively seeks to understand the needs of the customers and provide the highest standards of service.
• Dedication to Professionalism and Integrity - Demonstrates and promotes fair, honest, professional, and ethical behaviors that establishes trust throughout the organization and with the public we serve.
• Organizational Excellence - Takes ownership for excellence through one's personal effectiveness and dedication to the continuous improvement of our operations.
• Success through Teamwork - Collaborates and builds partnerships through trust and the open exchange of diverse ideas and perspectives to achieve organizational goals.

Duties and Responsibilities

Note: The following duties are illustrative and not exhaustive. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. Depending on assigned area of responsibility, incumbents in the position may perform one or more of the activities described below.

• Monitor procedural compliance of network providers.
• Pursue quality of care inquiries.
• Review medical records to determine accepted standards of care have been rendered and appropriately performed.
• Plan agenda and prepare materials for HCAB Medical Subcommittee and Drug Review Committee meetings and promote attendance.
• Attend Committee meetings and provide input and direction as applicable.
• Function as a quality assurance liaison between the networks, providers and hospitals on client issues.
• Participate and assist with the performance improvement programs of networks, providers and hospitals.
• Provide patient outcome feedback as requested.
• Identify training issues, prepares reports and related documentation.
• Execute special projects involving the care of HCHCP clients.
• Perform other special assignments, research and prepare reports, develop and implement programs.
• Performs other related duties as required.

Job Specifications

• Knowledge of nursing theory and practices.
• Knowledge of general medical and surgical nursing techniques and procedures.
• Knowledge of Quality Assurance policies and procedures.
• Knowledge of the National Committee on Quality Assurance (NCQA) standards.
• Knowledge of Utilization Review and Case Management policies and procedures.
• Knowledge of Disability Determination criteria.
• Ability to collect, organize and evaluate data and to develop logical conclusions.
• Ability to follow oral and written instruction and ability to use a computer and related software.
• Ability to prioritize work and work effectively with others.
• Ability to communicate effectively both orally and in writing.

Physical Requirements

• This position requires an employee to be able to sit for long periods of time and focus on complicated tasks.

Work Category

• Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Minimum Qualifications Required

• Possession of a valid State of Florida Registered Nurse license; AND
• Five years of general medical or surgical nursing experience to include two years performing Quality Assurance, Utilization Review or Case Management duties; AND
• Possession of a valid Florida Driver’s License.

Emergency Management Responsibilities

In the event of an emergency or disaster, an employee may be required to respond promptly to duties and responsibilities as assigned by the employee’s department, the County’s Office of Emergency Management, or County Administration. Such assignments may be for before, during or after the emergency/disaster.

Additional Job Requirements

A department, depending on the nature of its mission and operations, may require that employees in all or certain positions in this job classification:

1. Maintain the ability to pass the background checks required for the position. These background checks may include but are not limited to:

• Criminal History Background Check using Florida Department of Law Enforcement (FDLE) Criminal Justice Information Services (CJIS)
• Level 1 and Level 2 Background screening (Ch. 435 Florida Statutes)
• Child Abuse, Abandonment and Neglect Record Check using the State Automated Child Welfare Information System (SACWIS)
• Sex Offender and Sexual Predator record check using the list maintained by the Florida Department of Law Enforcement (FDLE)