Quality Nurse Specialist Jobs

The Quality Nurse Specialist (QNS) is selected by and reports to the Director of Surveillance Utilization Review of Surveillance Utilization Review (SUR). Works under minimal supervision, with extensive latitude for the use of initiative and independent judgment. The QNS coordinates the SUR quality review process regarding Medicaid admissions; maintains HIPAA privacy standards; and identifies potential fraud, waste, and abuse. The QNS will make referrals for investigation and to licensing boards and other state agencies if applicable. The QNS coordinates hospital compliance and payment error prevention process in conjunction with hospital utilization activities. The QNS provides training and educational opportunities for SUR nurses conducting hospital reviews, nursing facility reviews, acute care service reviews, Health and Human Services Commission staff, and the provider community. Performs utilization and quality reviews of referred cases from other HHSC departments or other state agencies. Summarizes quality outcomes for state and the federal waiver program annually. Identifies trends in quality and makes recommendations for improvement. The QNS performs quality reviews for the nursing facility program, hospital reviews and other SUR programs when applicable. The QNS represents SUR in agency, intra, and interagency meetings as requested. Performs other duties as assigned and required to maintain unit operations. Requires ability to travel up to 25% which may include some overnight travel.

Essential Job Functions:
Coordinates and conducts the SUR quality review processes regarding Medicaid admissions; maintains HIPAA privacy standards including review of medical records referred for quality concerns, tracks, and monitors responses to quality concern inquiries, and provides in writing decisions based on nurse reviewer response to provider documentation and findings. Answers inquiries regarding quality review process. Summarizes and aids in development of quality metrics and monitors the outcomes and maintains a quality case tracking database for state and the federal programs; develops annual reports and as requested. Identifies potential fraud, waste, and abuse and makes referrals for investigation and to licensing boards and other state agencies if applicable (40%).

Coordinates with Hospital Utilization (HUR), Acute Care Services (ACS), Nursing Facility Utilization (NFUR) teams compliance and over payment error prevention processes in conjunction with activities including development of reports for tracking and recommendations for compliance actions and may include development of reports for compliance notification, and monitoring responses of providers by coordinating with regional utilization review activities (15%).

Provides training and educational opportunities for the SUR team, the Health and Human Services Commission staff including physician consultants and the provider community. (15%).

Identifies trends in quality reviews and makes recommendations for improvement. Performs utilization and quality reviews of referred cases from other HHSC departments or other state agencies including requests for higher weight diagnostic related group changes (10%).

Represents SUR in agency, intra and interagency meetings as requested (5%).

Acts in the absence of manager or designee for hospital issues and procedures (5%).

Performs reconsideration reviews for the SUR programs including reviews of the utilization review documentation, development of response to provider of reconsideration determination, and data enters response in reconsideration application of case mix utilization review application and provides documentation to state office program specialist for file and record retention upon request. (5%)

Performs other duties as assigned and required to maintain unit operations (5%).

Knowledge Skills Abilities:
Knowledge of:

Utilization review, quality, and peer review processes/procedures.

Medical diagnoses, procedures, and acceptable treatment patterns. Inpatient hospital experience preferred.

And ability to utilize personal computer and corresponding applications including Microsoft Office (Word, Excel, Access, PowerPoint).

Training and educational development for adult learners.

Skill in:

Organizing workload and preparation of correspondence for provider community and physician consultant reviewers.

Ability to:

Analyze and evaluate detailed documentation to identify problems and make appropriate decisions.

Plan, perform, and evaluate educational opportunities through a variety of means.

Ability to plan, coordinate, and administer quality control program activities; to ensure compliance with state and federal regulations; to identify problems and develop solutions; to communicate effectively; and to supervise the work of others.

Communicate effectively and professionally with provider community by telephone and in writing.

Develop and maintain working relationships with all levels of staff, both internal and external to the agency.

Perform work with general supervision.

Travel up to 25% of the time with some overnight stays.

Lift and carry up to 25 pounds in weight.

Sit approximately 75% of the time.

Registration or Licensure Requirements:
This position requires the current licensure of a Registered Nurse in the state of Texas or compact licensure with a compact state.

Initial Selection Criteria:
Graduate of an accredited four-year college, university, or school of nursing.
Experience in utilization review
Experience in clinical quality review and peer review processes.

Additional Information:
This position is a hybrid position and may require coming into the office as needed for operational business needs.

**This position may be located at any OIG location in the State. **

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.

OIG will request that all applicants considered for an interview provide responses to essay questions. Failure to respond to the request could disqualify an applicant from the interview process.

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.
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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

Top 10 Tips for Success when Applying to Jobs at HHSC and DSHS

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.