Managed Care Utilization Review LTSS Nurse

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Functional Title: Managed Care Utilization Review LTSS Nurse
Job Title: Nurse III
Agency: Health & Human Services Comm
Department: UR LTSS FTE Random Mmt Study
Posting Number: 20572
Closing Date: 09/11/2026
Posting Audience: Internal and External
Occupational Category: Healthcare Practitioners and Technical
Salary Range: $5,425.33- $7,155.75
Pay Frequency: Monthly
Salary Group: TEXAS-B-24
Shift: Day
Additional Shift: Days (First)
Telework: Eligible for Telework
Travel: Up to 75%
Regular/Temporary: Regular
Full Time/Part Time: Full time
FLSA Exempt/Non-Exempt: Exempt
Facility Location:
Job Location City: SAN ANTONIO
Job Location Address: 1067 BANDERA RD
Other Locations: San Antonio; Alamo; Alice; Alvin; Aransas Pass; Beeville; Boerne; Brownsville; Carrizo Springs; Corpus Christi; Crystal City; Eagle Pass; Edinburg; Elsa; Falfurrias; Floresville; Goliad; Harlingen; Hondo; Karnes City; Kingsville; Laredo; Mcallen; Mercedes; Mission; New Braunfels; Pearsall; Pharr; Port Lavaca; Raymondville; Refugio; Rio Grande City; Robstown; San Benito; San Juan; San Marcos; Sinton; Victoria; Weslaco; Zapata
MOS Codes: 290X,46AX,46FX,46NX,46PX,46SX,46YX,66B,66C,66E,66F,66G,66H,66N,66P,66R,66S,66T,66W

Job Description:

Under the direct supervision of the UR nurse supervisor, the UR Nurse III conducts reviews of assessments, individual service plans (ISPs) and other relevant documentation to evaluate long term services and supports (LTSS) in Medicaid managed care; and to determine compliance with policies, procedures, rules, laws, contract standards, and correctness of needs assessments for Medicaid managed care LTSS. The UR nurse uses an array of evaluation methods, including review of records and face to face interviews with waiver members for validation of service needs and service delivery. The UR nurse uses program knowledge and nursing expertise to determine service needs and quality. This position has moderate latitude for use of initiative and independent nursing judgment in the required evaluations. The UR nurse III will be responsible for complex policy interpretations, validation of, or recommendations for clinical review decisions made by Medicaid managed care organizations (MCOs) and provider agencies. This position will also be responsible for timely and accurate reporting. The UR Nurse III will also be responsible for working collaboratively with MCOs and providers to ensure coinciding and/or mutually dependent functions are accomplished smoothly.

Essential Job Functions:

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Implements UR activities. Reviews MCO policies and procedures, nursing activities, medical records, assessments including medical necessity/level of care (MN/LOC), and ISPs, to determine compliance with policies and procedures, correctness of assessments, standards of care, and quality of service. Makes recommendations for improvement as a result of the reviews. 40% Produces routine and specialized data and information for program reports. 20% Responsible for timely and accurate reporting of program activities. 15%. Informs and collaborates with internal divisions as necessary on program outcomes. 10% Interprets complex state and federal laws, regulations, and rules related to the program. Perform other duties as assigned. 15%

Registrations, Licensure Requirements or Certifications:

State of Texas Registered Nurse license in good standing.

Knowledge Skills Abilities:

Knowledge of: nursing techniques and procedures; health care laws, rules, standards, and regulations; medical diagnoses and procedures; accepted medical treatment programs; community health and nursing care principles, practices and procedures; Medicaid and managed care regulations and procedures; utilization management and review principles and practices; and health care needs and services for the aged and disabled as well as pediatric special needs.

Skill in: organizing w