Nurse IV

Texas Health & Human Services Commission Austin, TX
The Nurse Research Analyst is selected by and reports to Division of Medical Services Manager within the Office of Inspector General, Health and Human Services Commission. Using advanced nursing knowledge; this position performs utilization review activities and consultative and technical work pertaining to research and development of information related to fraud, abuse, and/or waste cases in the Texas Medicaid Program. Extensive computer skills (Word, Excel, Office, Phoenix, Business Objects are used along with developing reports, spreadsheets and ICD 9 and 10 coding use). The Nurse Research Analyst works under minimum supervision with extensive latitude for the use of initiative and independent judgment. This position may require the Nurse Analyst to testify in court as a subject matter expert. The position will regularly perform other projects or duties as assigned and required to maintain the unit and section operations. Position may require up to 15% travel with infrequent overnight stays. May require work hours other than eight to five. Requires viewing the computer screens for long periods of time, up to six or more hours per day. Requires the ability to move and lift boxes of paper documents.Essential Job Functions:

1. Uses advanced nursing knowledge to review, analyze and refer suspect provider activity - 35% 2. Compares the MFADS Models, TQs, and utilization review and Ad hoc reports and processes for duplication/effectiveness - 20% 4. Performs advanced consultative and technical work applying nursing knowledge and specialized research related to fraud, abuse and/or waste cases in the Texas Medicaid Program - 15% 5. Participates in meetings with vendors, state and federal agencies, and operating agency staff to review fraud, abuse, and waste detection activities used in the evaluation of treatment/practice patterns - 10%6. Keeps abreast of current medical practices, changes in Medicaid Medical Policy and Program and effectively communicates and provides guidance and support to all IG and Medical Division staff in their analysis and monitoring of the state contractor in the claims processing system - 10% 7. Demonstrates interpersonal skills to facilitate team approach - 5% 8. Participates and performs other duties and assignments as required to maintain the division operations, including testifying in court as a subject matter expert. - 5%Knowledge Skills Abilities:

a. Knowledge of the Medicaid program, its rules and regulations and policies. Knowledge of Medicaid MIS, its components, processes, databases, systems, and protocols. Knowledge of the Medicaid operating agencies programs, guidelines, procedures and processes. Ability to apply nursing knowledge, practices and procedures to components of job and in consultation. Considerable knowledge of medical diagnoses, procedures and evaluation of accepted health care and treatment patterns. Knowledge of the theories of fraud, abuse, or waste as it relates to health care programs and/or the Medicaid Program. Knowledge of /or ability to apply quantitative and qualitative methods of analysis, detection, and measurements of fraud, waste or abuse. Skill in managing multiple, sometimes conflicting priorities without jeopardizing deadlines and schedules. Ability to recognize patterns of medically necessary treatment and assessment of appropriate use of medical services. b. Ability to interpret medical documents, including charts, narratives, plans of treatment and diagnosis. Ability to function well as a team member. Ability to use personal computers and assorted software. (Word, Excel, Access is preferred). Ability to effectively communicate both orally and in writing, particularly in providing consultation, interaction at meetings and in training of staff. Ability to establish and maintain positive, effective working relationships.Registration or Licensure Requirements:

Licensed to practice as an unrestricted Registered Nurse in the state of Texas or current unrestricted RN license in a state recognized by the Texas Compact Licensure Agreement. Bachelor's degree in Nursing preferred. Medical Coding Certification preferred.Initial Selection Criteria:

a. Current, unrestricted Texas RN license or current unrestricted RN license in a state recognized by the Texas Compact Licensure Agreement. b. Coding experience and/or coding certification preferred. c. 2 years utilization review or health care quality assurance experience required. d. MS office suite computer application experience, minimum 2 years. e. Consideration will also be given to known past job performance, if applicable and prior work history.Additional Information:

There will be an in-basket exercise at time of interview. Consideration will be given to known past job performance and prior work history. Job offer contingent upon successful completion of criminal background check. Criminal history background check may be required. Interview process includes work-related exercise. 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 Chapter 7. Req #382507MOS Code:

Note: Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include: 68C, 66N/P/W, 290X, 46FX, 46NX, 46SX. For more information see the Texas State Auditor's Military Crosswalk at

HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

I-9 Form - Click here to download the I-9 form.

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.

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