Nurse Iii Jobs

This position is a hybrid position and may require coming into the office as needed for operational business needs.
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 and analytical skills to conduct desk MDS assessment reviews and investigations, prepares reports and makes appropriate notifications regarding Medicaid recipients in Medicaid approved hospitals and nursing facilities; maintains HIPAA privacy standards; and identifies potential fraud, waste, and abuse. The NR coordinates the nursing facility onsite/desk and record review process across all state facilities treating patients under the Medicaid program. Conducts MDS assessment and reimbursement reviews in Medicaid approved nursing facilities to determine the accuracy of assessment data provided by the nursing facility to ensure accurate payment. Works under limited supervision with considerable latitude for the use of initiative and independent judgment. The NR performs other duties as assigned and required to maintain unit operations. The Nurse Reviewer may lift up to 40 lbs., walks extended distances and travels approximately 50% of the time with some overnight stays.

Essential Job Functions:
1. (40%) Uses technical and analytical skills to conduct investigations, and MDS assessment reviews in Medicaid approved nursing facilities (NFs) through onsite and desk reviews; must be able to meet performance metrics as required and will use advanced nursing knowledge to assure that Medicaid NFs are consistently adherent to rules, regulations, written policies, and procedures; and identify potential fraud, waste and abuse.
2. (40%) Uses technical and analytical skills to conduct utilization reviews on Medicaid recipients in Medicaid approved hospitals to determine necessity of admission and the accuracy of diagnosis and procedural coding and maintains HIPAA privacy standards while identifying potential fraud waste and abuse.
3. (15%) 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.
4. (5%) Conducts investigations and examinations of alleged violations of laws, rules, and regulations regarding fraud in Medicaid coding.

Knowledge Skills Abilities:
Knowledge of:

Case review, analysis evaluation, detailed case documentation, defining problems and making appropriate decisions.

Medical diagnosis, procedures and accepted medical treatment patterns.

Federal and state laws governing Medicaid policies and procedures and long-term care facilities.

resident assessment instrument, MDS items and form completion.

Skill in:

Interviewing techniques, organization of work and multiple tasks.

Communicating effectively, orally and in writing.

Establishing and maintaining effective working relationships.

Ability to:

Work under pressure, perform work under general supervision.

Maintain a professional attitude.

Apply nursing knowledge, practices, and procedures to components of job and in consultation; particularly the ability to interpret medical documents, including charts, narratives, plans of treatment and diagnosis

Conduct fraud and abuse investigations.

Apply methods of analysis, detection, and measurement of fraud, waste, and abuse.

Interpret and apply policies, procedures, and regulations.

Use personal computers and related software.

Work under limited supervision, plan, prioritize and coordinate work in an independent manner, complete assigned tasks, and meet metrics.

Work productively in a telework environment. Must be able to provide sufficient internet capability and speed necessary to support program work under VPN.

Maintain a regular and predictable work schedule.

Travel extensively (up to 50%) with some overnight travel required

Registration or Licensure Requirements:
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.

Initial Selection Criteria:
Graduation from an accredited school of professional nursing, college, or university is required.
Experience in use of personal computers and related software.
Experience in a telework/ mobile environment.
Full time experience in nursing facility administration and/or utilization review is highly desirable.
Prefer knowledge of MDS 3.0.

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.
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.
This position is a hybrid position and may require coming into the office as needed for operational business needs. 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 submit to a name-based, or in some instances a fingerprint based, criminal background check through Texas Department of Public Safety (DPS) to determine if an applicant has a conviction for a Class A misdemeanor within the last five years or a felony that constitutes a bar to employment.
The posted salary range reflects the minimum and maximum allowable by state law. Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual.
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 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.

MOS Code:
68C, 66N/P/W, 290X, 46FX, 46NX, 46SX
All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information see the Texas State Auditor’s Military Crosswalk at http://www.hr.sao.state.tx.us/Compensation/JobDescriptions.aspx.