State of Washington
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Occupational Nurse Consultant (ONC/MPOI)
at State of Washington
Job Status: Full Time
Job Reference #: 2597619
Categories: Healthcare - RNs & Nurse Management
Overall Job Objective
Occupational Nurse Consultant (ONC/MPOI)
The ideal candidate for this position will have the ability to independently manage multiple projects with competing deadlines. If you are adept at analyzing and resolving complex problems, and pride yourself on writing clear narrative and analytical reports, this may be the opportunity for you!
The purpose of this Occupational Nurse Consultant (ONC) is to provide clinical quality assurance as a member of the team that performs federally required oversight of HCA-contracted Managed Care Organizations (MCO) and contractual compliance monitoring of the Behavioral Health-Administrative Service Organizations (BH-ASO).
This position uses clinical expertise and judgment to perform compliance reviews of clinically-oriented topical areas (e.g., Quality Assessment and Performance Improvement, Performance Improvement Projects, Care Coordination) as well as, file reviews of individual client care and services. The position reviews MCO and BH-ASO materials and applies clinical judgment and analytical skills to assess and evaluate the quality and completeness of information according to Federal regulations and national quality standards. This position writes corrective action plans for MCOs and BH-ASOs and monitors them to resolution.
This position will develop tools and processes to monitor and oversee care and services provided to clients, conduct periodic monitoring reviews of care and services, share findings with Contractors, and provide technical assistance to improve care and services. This role monitors and reviews care and services provided to populations served within the Apple Health managed care delivery system, focusing on special populations, such as medically-complex clients, individuals with co-occurring behavioral health diagnoses, individuals with intellectual or developmental disabilities, and children and youth served by the child welfare system.
Some of what you will do:
Provide clinical judgment and expertise to perform compliance reviews of MCOs and BH-ASOs in clinical areas as part of TEAMonitor formal monitoring and oversight activities. Implement corrective action and provide technical assistance to the MCOs and BH-ASOs to improve clinical areas and quality outcomes as needed.
- Written evaluation and analysis of MCO and BH-ASO documentation related to clinically-based topical areas, such as Coverage and Authorization of Services/Utilization Management, Grievance and Appeal System, Provider Credentialing, Care Coordination, Quality Assessment and Performance Improvement, and Practice Guidelines.
- Review clinically-related client files (e.g., authorization denials, appeals, care coordination, credentialing) to assess compliance with federal, state and contractual requirements, such as regarding medical necessity determinations, adherence to timelines, and clinically appropriate follow-up.
- Develop corrective action based on findings.
- Individual case investigation and resolution of enrollees experiencing difficulty or delay accessing medically necessary services.
- Review of client health care utilization history, claims/encounter history, managed care enrollment, and/or medical records, as appropriate.
- Work collaboratively with MCO, BH-ASO, and HCA staff to investigate individual cases and identify ways to improve overall services. Opportunities for improvement may include providing guidance or formal advisory notifications to MCOs or BH-ASOs or recommending revisions to Medicaid Billing Guides, Service Encounter Reporting Instructions (SERI), contractual requirements, or Washington Administrative Code (WAC).
- A minimum of a Bachelor's Degree in Nursing required.
- Current Registered Nurse licensure in Washington State.
- Two (2) years' experience in quality assurance and improvement principles and approaches
- Experience in Medicaid managed care operations
- Experience in contract management and accountability
- Experience in Utilization Review activities
The Washington State Health Care Authority (HCA) purchases health care for more than 2 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, and, beginning in 2020, the School Employees Benefits Board (SEBB) Program. Our agency is committed to whole person care, integrating physical health and behavioral health services for better results and healthier residents. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.
About Olympia and Washington State
Washington State offers a total work/life package of pay, benefits, flexibility, and workplace opportunities to help you get the most out of your career and out of life. Washington State is a great place to work, play, and be a part of a community, offering quality of life that is unsurpassed. From the high energy urban center of Seattle, one of the nation's top ranked cities, to the more relaxed pace of our rural communities, Washington's distinctive Northwest lifestyle blends a progressive, creative culture with a casual nature.
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 and attach:
- A cover letter that specifically addresses how you meet the qualifications for this position
- Current resume
- Three professional references, including a minimum of one past supervisor
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 360.725.1180 or email Sanyu.Tushabe@hca.wa.gov.
*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 but will be considered in determining the applicant's suitability and competence to perform in the position. *