Washington State Occupational Nurse Consultant (71029062) in Olympia, Washington
Occupational Nurse Consultant (71029062)** Full-time, Permanent Olympia, WA
The Health Care Authority (HCA) is Washington's largest health care purchaser, responsible for providing comprehensive health coverage to more than 2 million residents through the Public Employees Benefits and Medicaid programs. The agency provides health purchasing leadership, benefiting both public and private sectors with a focus on moving the health delivery system away from volume toward higher value and better outcomes.
The Olympia office is located in downtown Olympia, within walking distance of shops, restaurants, bus lines, and less than one mile from the freeway.
Position Objective: The Office of Program Integrity's (OPI's) mission is to identify and prevent improper payments. This position conducts retrospective clinical review of healthcare provider data, claims and/or records to identify improper payments and assist with policy development to prevent improper payments.
A retrospective clinical review conducted by this position 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. Retrospective clinical reviews may result in one or more of the following:
- Recovery of funds inappropriately or excessively paid.
- Focused and/or general provider education and training.
- Referral for potential client or provider over-utilization or misuse of medical assistance benefits and/or services.
- Referral for potential prosecution of Medicaid fraud.
- Referral for potential quality of care and/or licensing concerns.
- A provider's termination from participation in Washington State's Medicaid program.
- Identification of medical assistance program vulnerabilities. This position will perform the following work: Conduct independent comprehensive review and analysis of inpatient and outpatient medical records, with a primary focus in behavioral health and provider preventable conditions.
- Evaluate the adequacy, appropriateness, and conformance with nationally recognized utilization review standards used to measure medical necessity and appropriate level of care; as well as compliance with agency, department, state and federal policies, rules and regulations.
- Exercise professional judgment, work independently with minimal supervision, and utilize time and resources effectively.
- 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 healthcare records to determine if diagnosis and procedure coding is accurate and make referral to coding staff for further evaluation as appropriate.
- Analyze documentation in healthcare records to verify services billed were ordered and provided.
- Refer cases identified as having potential fraud and abuse to the Medicaid Fraud Control Unit (MFCU) and/or other law enforcement entity for further investigation.
- Refer cases identified as having potential quality of care or licensing issues to the agency's Quality Management Team and/or Department of Health (DOH).
- Support peers by coaching and mentoring clinical review protocols and through the inter-rater reliability review process.
- Accurately document determinations on appropriate review sheets, case tracking logs, and/or in the audit module.
- Respond timely and accurately to written and/or oral questions regarding retrospective clinical review findings and/or the retrospective clinical 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.
- Participate in and provide feedback to internal and external workgroups and steering committees.
- Collaborate with non-clinical medical and hospital audit staff on audits and potential fraud cases, providing clinical expertise as requested.
- Facilitate and/or participate in meetings with intra-agency, inter-agency, contractors, and/or provider groups, and provide education or training when needed.
- Use creative and innovative approaches to achieve results and resolve problems. Specific to inpatient hospital Provider Preventable Conditions (PPC) audits, abide by the tasks listed above and:
- Evaluate hospital stays for provider preventable conditions (PPC) and determine if those conditions affected the payment.
- Coordinate record requests for PPC reviews with other auditors in the clinical review unit.
Required Qualifications: Education and experience requirements for the nurse auditor are:
A Master's degree in Nursing (MN) with a minimum of five years clinical experience in the acute care setting and a minimum of two years experience in utilization review or case management;
A Bachelor's of Science in Nursing (BSN) degree with a minimum of five years clinical experience in the acute care setting and a minimum of two years experience in utilization review or case management;
An Associates in Nursing degree with a minimum of eight years clinical experience in the acute care setting and a minimum of two years experience in utilization review or case management;
Any aforementioned nursing degree with a minimum of five years clinical experience in the acute care setting and a Certified Professional of Utilization Review (CPUR), or Certified Professional in Healthcare Management (CPHM), or Certified Case Manager (CCM).
Required skills and abilities: Working knowledge of current concepts in nursing.
Working knowledge of procedures, skills, and techniques of nursing service administration.
Working knowledge of philosophy of nursing education.
Knowledge of social sciences.
Knowledge of healthcare practices under the State's medical care programs.
- Working knowledge of clinical theory and practice of hospital-based care, with a focus in behavioral health.
- Working knowledge and ability to analyze inpatient and outpatient healthcare records for appropriate medical intervention; and make independent decisions about the adequacy, appropriateness, and conformance with nationally recognized standards and criteria used to evaluate medical necessity and level of care.
- Ability to learn and use applicable standards, criteria, software, databases, and tracking systems used in the retrospective clinical/utilization review process and in the identification of potential fraud and abuse.
- Ability to exercise professional judgment, work independently with minimal supervision, and utilize time and resources effectively.
- Knowledge of state and federal rules and regulation; agency rules, policies and procedures pertaining to Washington State's Medicaid and Medical Assistance programs.
- Knowledge of Health Insurance Portability and Accountability Act and Personal Health Information privacy rules, regulations, and policies.
- Knowledge of the ProviderOne payment system.
- Knowledge of the State's medical assistance program cost reimbursement methodologies and regulations.
- Knowledge and ability to recognize inappropriate ICD-9-CM and CPT coding.
- Written and verbal communication skills, to include public speaking and negotiation.
- Working knowledge of Microsoft Office products and Internet.
- Ability to work effectively in an adversarial environment.
- Knowledge of the Health Care Authority organization, mission and goals.
Familiarity with and an understanding of audit standards established by the U. S. Government Accountability Office (GAO) in the publication Government Auditing Standards (GAS). How to Apply: Failure to follow the application instructions below may lead to disqualification. To apply for this position you will need to complete your profile within http://careers.wa.gov and attach to your profile before completion:
A cover letter
- Current resume
- Three professional references Only candidates who reflect the minimum qualifications on their State application will be considered.
If you have questions about the process, or need assistance, please contact the recruiter listed below before the posting closes. The candidate pool certified for this recruitment may be used to fill future similar vacancies for up to the next six months.
For inquiries about this position, please contact Ryan Dahlstromat 360-725-0945 or email to firstname.lastname@example.org.
**Persons under final consideration for initial appointment with HCA are subject to a background check.
Washington State is an equal opportunity employer. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may call the Human Resources Office at 360.725.0945 or email@example.com.
Job Type: Full Time - Permanent
Job Number: 2016-09998
Department: Health Care Authority
Agency: State of Washington
Address: View Job Posting for Agency Information View Job Posting for Location, Washington, 98504.
Salary: $58,056.00 - $95,184.00 Annually
Location: Thurston County – Olympia, WA