Occupational Nurse Consultant (Onc/Daio)

Occupational Nurse Consultant (ONC/DAIO)

71053213

This position performs reviews of inpatient and outpatient health care with a particular focus on certified public expenditure (CPE) hospital reviews. The ONC will quickly get up to speed on a wide range of billing guides and WACs that dictate the work of this team that ensures proper use of Medicaid dollars. The ideal candidate will have experience with hospital nursing, clinical documentation review, auditing, and/or nurse coding along with enthusiasm for performing important work to preserve taxpayer dollars and in service to the people of Washington.

All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes.

About the division and position:

The Division of Audit, Integrity, and Oversight's (DAIO) mission is to identify and prevent improper payments resulting from fraud, waste, and abuse. The incumbent reports to the Inpatient Audit / Clinical Review Unit Supervisor and conducts pre-payment and retrospective clinical review of health care provider claims data and health care records to assess, identify, and recovery of improper payments.

A pre-payment or retrospective clinical review conducted of both Apple Health Medicaid fee-for-service (FFS) and HCA-contracted Managed Care Organization (MCO) paid claims by the incumbent will assess if billed services were: Actually ordered and provided, medically necessary, provided at the appropriate level of care, of good quality and compliant with federal, state and agency policies, rules and regulations. This position may participate in fraud and abuse investigations.

This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions - both on-site and telework eligible positions - is within the State of Washington. Frequency of onsite work will vary based on business and operational needs. HCA may choose, but is not required, to support out-of-state telework on a case-by-case basis.

Some of what you will do:

• Evaluate the adequacy, appropriateness, and conformance with nationally recognized utilization review standards used to measure medical necessity and appropriate level of care.

• Verify facility-related line-item charges are Medicaid covered services and whether billed services are following agency, department, state, and federal policies, rules, and regulations.

• Apply clinical theory and practice of hospital-based care as well as pertinent agency, state, and federal codes, rules, regulations, policies, guidelines, publications, and patient care standards when conducting retrospective clinical review.

• Analyze documentation in health care records to determine if diagnosis and procedure coding is accurate and make referral to coding staff for further evaluation as appropriate.

• Analyze documentation in health care records to verify services billed were ordered and provided and medically necessary.

• Review health care records and analyze documentation to determine if services that were paid or provider request for payment are Apple Health Medicaid covered services.

• Conduct audits of MCO-contracted providers to identify potential fraud, waste, or abuse.

• Support peers by coaching and mentoring clinical review protocols and through the inter-rater reliability review process.

• Participate in provider dispute resolution process and administrative hearing process, including providing evidence and/or testimony in support of retrospective clinical review findings.

• Provide recommendations to executive and program management to prevent vulnerabilities and strengthen program policies and procedures.

• Collaborate with data experts to design reports for review and analysis to identify medical program vulnerabilities and trend provider billing baseline and patterns.

Required qualifications:

Qualifying candidates will have a valid Washington State or multi-state license to practice as a registered professional nurse and will satisfy one of the following criteria options:

Option 1:

• Three years of clinical or functional nursing experience, and

• Two years of consultative, administrative, or supervisory experience over registered nursing staff or other health care professionals.

Option 2:

• Bachelor's degree will substitute for the two years of administrative, consultative or supervisory experience and

• Three years of clinical or functional nursing experience.

Option 3:

• Master's degree in a health care field and

• Two years of clinical or functional nursing experience.

Required competencies:

• Successful communication, decision making, and interpersonal skills.

• Knowledge and application of standards of medical practice, medical records, medical procedures, and ethics.

• Knowledge and ability to conduct literature reviews and apply evidence-based medical principles in clinical decision-making.

• Ability to analyze data and medical record documentation, applying utilization review principles to determine how medical practices affect client health and safety, and whether the services met accepted clinical practice guidelines.

• Excellent, clear, concise, accurate and effective oral and written communication of clinical facts and recommendations directed to healthcare providers, professional and para-professional staff in government.

• Ability to exercise professional judgment, work independently with minimal supervision, and utilize time effectively.

• Ability to establish and maintain effective relationships with providers and staff in HCA and other agencies.

• Ability work effectively in a team, with peers, managers, health care providers, managed care organizations, law enforcement entities, and others.

• Working knowledge and ability to use computer software programs, systems and databases, e.g., MS Word, MS Excel, MS Access.

Preferred qualifications:

• Knowledge of:

• Current and developing trends in medical healthcare delivery systems and billing, including managed care; or case management/utilization management or review activities.

• Certified Public Expenditure (CPE) program.

• Medicaid rate settling and cost settlement.

• Federal and state rules and regulations related to health care, utilization review, program integrity, and Medicaid; and pertinent HCA policy and contract requirements in oversight activities.

• Medicaid program integrity principles.

• Health Insurance Portability and Accountability Act and Personal Health Information privacy rules, regulations, and policies.

• Medical coding principles and guidelines for CPT, HCPCS and ICD-10.

• Health Care Authority's organization, mission, values, and goals.

• High degree of initiative, self-starter, goal-oriented, and ability to motivate individuals to achieve targeted and measurable results.

• Certified Coding Specialist (CCS), or Certified Professional Coder (CPC) certification.

• High competency level in formal report writing, following standard styles such as the American Psychological Association (APA) or the Modern Language Association (MLA) formatting.

How to apply:

Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position, you will need to complete your profile which includes three professional references and attach:

• A cover letter that specifically addresses how you meet the qualifications for this position

• Current resume

To take advantage of veteran preference, please do the following:

• Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter.

• Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov.

About HCA:

Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents.

What we have to offer:

• Meaningful work with friendly co-workers who care about those we serve Voices of HCA 

• A clear agency mission that drives our work and is person-centered HCA's Mission, Vision & Values

• A healthy work/life balance, including alternative/flexible schedules and mobile work options.

• A great total compensation and benefit package WA State Government Benefits

• A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby.

• Tuition reimbursement

• And free parking!

Notes:

Please note, salary is based on experience and is determined at the time a final offer of employment is made. Per StateHR guidance, nursing salaries are considered a "special pay range" and details on that range can be found here: N Range details.  The salary range listed in the job posting includes steps A-U. Step U is a longevity step and is typically gained six years into being assigned step T in your permanent salary range.

Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment.

HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA's mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace. Studies have shown women, racial and ethnic minorities, and persons of disability are less likely to apply for jobs unless they feel they meet every qualification as described in a job description. Persons over 40 years of age, disabled and Vietnam era veterans, as well as people of all sexual orientations and gender identities are also encouraged to apply. If you have any questions about the required qualifications or how your experience relates to them, please contact us at HCAjobs@hca.wa.gov. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may contact Jake Nelko at jake.nelko@hca.wa.gov or 360.725.0945.

The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.

E-Verify is a registered trademark of the U.S. Department of Homeland Security.

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