Hillsborough County Government logo or seal
Hillsborough County Government

Healthcare Svcs Review Nurse (#HCSVRNGENQ) GENQ
$22.23-$35.30 Hourly / $3,853.20-$6,118.67 Monthly / $46,238.40-$73,424.00 Yearly




JOB OVERVIEW

Performs duties reviewing patient charts at contracted hospitals and clinics to determine if the quality and utilization of services are within established guidelines.

MINIMUM QUALIFICATIONS

Possession of a valid State of Florida Registered Nurse license; and

Five years of general medical or surgical nursing experience to include two years performing Quality Assurance, Utilization Review or Case Management duties; and

Possession of a valid Driver License.

 

Or an equivalent combination of education, training and experience that would reasonably be expected to provide the job-related competencies noted below.

CORE COMPETENCIES

  • Customer Commitment - Proactively seeks to understand the needs of our customers and provide the highest standards of service.
  • Dedication to Professionalism and Integrity - Demonstrates and promotes fair, honest, professional and ethical behaviors that establishes trust throughout the organization and with the public we serve.
  • Organizational Excellence - Takes ownership for excellence through one's personal effectiveness and dedication to the continuous improvement of our operations.
  • Success through Teamwork - Collaborates and builds partnerships through trust and the open exchange of diverse ideas and perspectives to achieve organizational goals.

JOB SPECIFIC COMPETENCIES

  • Considerable knowledge of nursing theory and practices.
  • Considerable knowledge of general medical and surgical nursing techniques and procedures.
  • Considerable knowledge of the statistical measurement tool (HEDIS) and Quality Assurance indicators.
  • Considerable knowledge of Quality Assurance policies and procedures.
  • Considerable knowledge of the National Committee on Quality Assurance (NCQA) standards.
  • Considerable knowledge of Utilization Review and Case Management policies and procedures.
  • Considerable knowledge of Disability Determination criteria.
  • Ability to collect, organize and evaluate data and to develop logical conclusions.
  • Ability to follow oral and written instruction.
  • Ability to prioritize work.
  • Ability to work effectively with others.
  • Ability to communicate effectively both orally and in writing.
  • Ability to use a computer and related software.

REPRESENTATIVE DUTIES

Note: The following duties are illustrative and not exhaustive. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. Depending on assigned area of responsibility, incumbents in the position may perform some or all of the activities described below.

  • Develops and defines policies and procedures related to Quality Assurance and/or Utilization Review.
  • Conducts onsite review of patient charts at contracted hospitals and clinics to determine if guidelines are met.
  • Prepares and submits written findings and corrective action plan recommendations to the Medical Director on non-compliance cases.
  • Advises assigned network staff regarding HealthCare Plan policies and procedures to ensure client needs are met.
  • Assists the Medical Director and Peer Review Committee in the development of Quality Assurance criteria.
  • Performs Disability Determination on assigned cases.
  • Approves the purchase of durable medical equipment and supplies for assigned network clients to ensure quality of care and appropriate use of resources.
  • Conducts special studies as directed by management.
  • Maintains work related records and reports.
  • Attends client appeals as required.
  • Inputs utilization review determinations and related pre-certifications in the computer.
  • Performs medical case management of client within assigned network.
  • Performs other related duties as required.

CLASS: HCSVRNGENQ; EST: 4/21/1999; REV: 7/15/2011;