Nurse III – Health & Human Services Comm – Austin, TX

The Quality Nurse Specialist (QNS) is selected by the Manager Hospital Utilization Review and Lock-In Program with the approval of the ADIG Medical Services. The QNS works under limited supervision with considerable latitude for the use of initiative and independent judgment. The QNS coordinates the quality review process, physician peer review, for acute care inpatient hospital admissions and freestanding child/adolescent psychiatric hospital admissions maintaining HIPAA privacy standards. Identifies potential fraud, waste, and abuse and makes 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 Quality nurse specialist provides training and educational opportunities for utilization review nurses conducting hospital 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 reconsideration reviews for the nursing facility program, when applicable. The QNS represents the utilization review program in agency, intra and interagency meetings as requested. The QNS acts in the absence of Hospital Utilization Review Manager or designee for hospital issues and procedures. 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:
The Quality Nurse Specialist (QNS) works under limited supervision with considerable latitude to coordinate the quality review process, physician peer review, for acute care inpatient hospital admissions and freestanding child/adolescent psychiatric hospital admissions maintaining HIPAA privacy standards including review of medical records referred for quality concerns, development of reports and forms for physician consultant review, track and monitor responses to quality concern inquiries, and provide in writing decisions based on physician response to provider documentation. Answers inquiries regarding quality review process. Summarizes quality outcomes and maintains quality case tracking database for state and the federal waiver program; develops reports annually and as requested for waiver and intra-agency inquiries. Identifies potential fraud, waste, and abuse and makes referrals for investigation and to licensing boards and other state agencies if applicable (40%). The QNS coordinates hospital compliance and payment error prevention process in conjunction with hospital utilization activities including development of reports for tracking and recommendations for compliance action and may include development of reports for compliance notification, and monitoring response of provider by coordinating with region utilization review activities (15%). The Quality nurse specialist provides training and educational opportunities for utilization review nurses conducting hospital reviews, Health and Human Services Commission staff including physician consultants and the provider community. (15%). Identifies potential fraud, waste, and abuse and makes referrals for investigation and to licensing boards and other state agencies if applicable. Identifies trends in quality 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%). The QNS represents the utilization review program in agency, intra and interagency meetings as requested (5%). The QNS acts in the absence of Manager or designee for hospital issues and procedures (5%). The QNS performs reconsideration reviews for the nursing facility program including review of nursing facility and 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. The QNS performs hospital utilization reviews 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. Knowledge of medical diagnoses, procedures and acceptable treatment patterns. Inpatient hospital experience preferred. Knowledge of personal computer applications including Microsoft Office (Word, Excel, Access, PowerPoint). Knowledge of 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. Ability to plan, perform, and evaluate educational opportunities through a variety of means. Ability to communicate effectively and professionally with provider community by telephone and in writing. Ability to develop and maintain working relationships with all levels of staff, both internal and external to the agency. Ability to perform work with general supervision. Ability to travel up to 25% of the time with some overnight stays. Ability to lift and carry up to 25 pounds in weight. Ability to 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:
Registered Nurse in the state of Texas or compact licensure with a compact state. Graduate of an accredited four-year college, university or school of nursing. Experience in utilization review or quality review or peer review processes. Ability to travel up to 25%.

MOS Code:
Note: Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to: 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.