Nurse Reviewer

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. Functional Title: Nurse Reviewer Job Title: Nurse III Agency: Health & Human Services Comm Department: Med Svcs-Quality Review TK Posting Number: 16324 Closing Date: 10/27/2026 Posting Audience: Internal and External Occupational Category: Healthcare Practitioners and Technical Salary Range: $5,833.33- $6,666.67 Pay Frequency: Monthly Salary Group: TEXAS-B-24 Shift: Day Additional Shift: Days (First) Telework: Eligible for Telework Travel: Up to 10% Regular/Temporary: Regular Full Time/Part Time: Full time FLSA Exempt/Non-Exempt: Exempt Facility Location: Job Location City: AUSTIN Job Location Address: 4601 W GUADALUPE ST Other Locations: MOS Codes: 290X,46AX,46FX,46NX,46PX,46SX,46YX,66B,66C,66E,66F,66G,66H,66N,66P,66R,66S,66T,66W 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 the requirements of Texas Medicaid as well as state and federal law. The nurse reviewer works under limited supervision with considerable latitude for the use of initiative and independent judgment. The NR reviews hospital records to validate medical necessity, accurate diagnoses and procedure codes by reviewing care plans, medical records, and patient assessments to verify adherence to medical coding guidelines, the accuracy of clinical evaluations, and the consistent delivery of quality care in hospital 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. Travels approximately 10% of the time with some overnight stays. Essential Job Functions: (40%) Conducts ongoing retrospective reviews of nursing facility records using technical skills, analytical skills, and clinical expertise to determine whether facilities correctly assessed residents needs, reimbursements were appropriate for the level of care, and care provided was medically necessary; Meets established performance metrics as established by OIG leadership; Applies advanced nursing knowledge to determine whether Medicaid NFs adhere to rules, regulations, written policies, and procedures; and identifies potential fraud, waste and abuse; Maintains confidentiality and HIPAA privacy standards in fulfillment of job duties. (40%) Conducts ongoing retrospective reviews of hospital records using technical skills, analytical skills, and clinical expertise to determine necessity of admission and the accuracy of diagnosis and procedural coding using Federal coding guidelines to validate the accuracy of billing; Meets established performance metrics as established by OIG leadership; Applies advanced nursing knowledge to determine whether Medicaid hospitals adhere to rules, regulations, written policies, and procedures; and identifies potential fraud, waste and abuse; Maintains confidentiality and HIPAA privacy standards while identifying potential fraud waste and abuse. (15%) Interacts professionally with Texas Medicaid providers, external stakeholders, and OIG colleagues in performance of job duties. Follows established policies, procedures, guidance, and direction when conducting reviews. Works under limited supervision with considerable latitude in professional judgement to perform assignments and other duties as assigned and required to ensure the overall efficient functioning of the division. Standards of performance are applied at the time of task assignment and management. (5%) Support investigations and other OIG divisions in the examination of alleged violations of laws, rules, and regulations in Texas Medicaid. Licensure Requirements and Certifications: Licensed to practice as a Registered Nurse in the State of Texas or in a state recognized under the Compact Licensure Agreement. License is current and in good standing. Applicant must be RAC-CT (Resident Assessment Coordinator) certified or be willing to obtain certification within six (6) months of start date. Initial Screening Criteria: Graduation from an accredited school of professional nursing, college, or university is required. Experience using a personal computer and Microsoft software in a telework/remote environment. Minimum of 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) preferred. Additional Information: In-basket exercise. Upon final selection and contingent offer, candidate must provide a certified copy of a college transcript and submit to a criminal history background verification. The OIG is responsible for preventing, detecting, auditing, inspecting, reviewing, and investigating fraud, waste, and abuse in the provision of HHS in Medicaid and other HHS programs. Potential employees of OIG are subject to criminal background checks in accordance with the HHS Human Resources policy. Selected applicants must complete a national fingerprint-based criminal background check through the Texas Department of Public Safety (TDPS) and Federal Bureau of Investigations (FBI) to determine if they have criminal history record information that constitutes a bar to employment. HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work. In compliance with the Americans with Disabilities Act (ADA), HHS 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 View phone number on click.appcast.io. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview. MOS Code: 68C, 66N/P/W, 290X, 46FX, 46NX, 46SX Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC. 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 View phone number on click.appcast.io. 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.