Occupational Nurse Consultant (ONC/DAIO)

at  Washington State Health Care Authority

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.

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.

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. (Download PDF reader) 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.
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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.