NURSE EVALUATOR II, HEALTH SERVICES

Department of Health Care Services; New York (NY); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

Paid holidays and vacation

Defined retirement program

Savings Plus Program (401(k), 457)

Employee Assistance Program (EAP)

Diversity, Equity, and Inclusion

Job summary

Department of Health Care Services (DHCS) is seeking a Nurse Evaluator II to join the Clinical Assurance Division. The role involves professional nursing duties within the medical review team, including utilization review, TAR adjudication, and post-claims oversight to ensure services meet medical necessity.

Travel up to 5% statewide is required for outreach and meetings. New state hires start at the minimum of the classification or alternate range based on experience.

Qualifications

• Professional nursing experience
• Experience with medical reviews and TAR adjudication
• Willingness to travel statewide up to 5% for meetings and provider outreach

Responsibilities

• Perform utilization review and post-claims oversight as part of the medical review team.
• Adjudicate Treatment Authorization Requests (TARs) to ensure medical necessity and Medi-Cal policy compliance.
• Review patient histories and medical records; prepare draft reports for fair hearings.
• Provide guidance to providers, beneficiaries, and other Department staff on medical policies and procedures.
• Travel statewide up to 5% of time for meetings and provider outreach.

Skills

Nursing skills

Utilization review

Medical record review

Job description

Job Description and Duties

Why Join DHCS? The Department of Health Care Services (DHCS) is the backbone of California’s health care safety net. Our success is made possible by the hard work of more than 4,800 DHCS team members and through collaboration with the federal government and other state agencies, counties, and partners for the care of low-income families, children, pregnant women, older adults, and persons with disabilities. This is an exciting opportunity to join our diverse team in the following role.

About this Role:

Under direction of the Nurse Evaluator III in the Department of Health Care Services' (DHCS) Clinical Assurance Division (CAD), the Nurse Evaluator II (NE II) performs professional nursing duties as part of the medical review team, including utilization review, post-claims oversight, and adjudication of Treatment Authorization Requests (TARs) to ensure services provided to Medi-Cal beneficiaries meet medical necessity and comply with Medi-Cal policy. The NE II reviews patient histories and medical records, prepares draft reports and responses for fair hearings, and provides guidance to providers, beneficiaries, and other Department and government staff on medical policies and procedures. Travel statewide, including overnight, of up to 5% of the time, by airplane, train, automobile, and other transportation methods is required to perform job related tasks such as attend meetings and conduct provider outreach. Travel related duties are dependent upon workload and operational need. New to state candidates will be hired into the minimum salary of the classification or minimum of the alternate salary range when applicable. Placement to alternate range may be based on education or experience identified in your state application.

Examination Information:

In order to be considered for the vacancy, all candidates must be eligible for appointment. If you already have list eligibility for this classification, you do not need to retake the examination, except when your list eligibility expires. This position is designated under the Conflict of Interest Code. The position is responsible for making or participating in the making of governmental decisions that may potentially have a material effect on personal financial interests. The appointee is required to complete Form 700 within 30 days of appointment and once per year. Failure to comply with the Conflict of Interest Code requirements may void the appointment.

Who May Apply

Individuals who are currently in the classification, eligible for lateral transfer, eligible for reinstatement, have list or LEAP eligibility, are in the process of obtaining list eligibility, or have SROA and/or Surplus eligibility (please attach your letter, if available). SROA and Surplus candidates are given priority; therefore, individuals with other eligibility may be considered in the event no SROA or Surplus candidates apply. Applications will be screened and only the most qualified applicants will be selected to move forward in the selection process. Applicants must meet the Minimum Qualifications stated in the Classification Specification(s).

Contact Information

The Hiring Unit Contact is available to answer questions regarding the position or application process. Hiring Unit Contact: Lani Su Please direct requests for Reasonable Accommodations to the interview scheduler at the time the interview is being scheduled. You may direct any additional questions regarding Reasonable Accommodations or Equal Employment Opportunity for this position(s) to the Department's EEO Office. EEO Contact: EEO Officer

California Relay Service

California Relay Service: (TTY), (Voice)TTY is a Telecommunications Device for the Deaf, and is reachable only from phones equipped with a TTY Device.

Telework and Salary Information

Telework: This position is currently eligible for telework. The amount of telework is at the discretion of the Department and is subject to change consistent with DHCS’ Telework Program and Government Code sections 14200 - 14203. Telework is available to California residents, and proof of residency may be required. Business travel may be required, and reimbursement considers an employee’s designated office and residence subject to regulations and bargaining unit contract provisions. All commute expenses to the reporting location will be the responsibility of the selected candidate.

Personal Leave Program (PLP) 2025 agreement Salary: Effective July 1, 2025, the California Department ofHuman Resources (CalHR) implemented the temporaryPersonal Leave Program 2025 (PLP 2025). PLP 2025 directs that each employee receive a temporary reduction in pay in exchange for PLP 2025 leave credits. The temporary salary reduction percentage and the number of PLP 2025 leave credits are based on the position’s associated bargaining unit. The salary range(s) included in this job advertisement do not include the temporary salary reduction. Please reach out to the hiring unit contact listed on this job advertisement for details.

Benefits

DHCS is dedicated to creating an innovative workplace for its team members that is inclusive, diverse, and interactive! Here are a few of the ways we stay engaged with our team and the benefits you may be eligible for:

• Continuous and ongoing training
• Diversity, Equity, and Inclusion program activities
• Employee Assistance Program (EAP)
• Medical, including health, dental, and vision insurance.
• Paid Holidays and vacation/leave
• Defined retirement program
• Savings Plus Program (401(k), 457)
• Medical/Dependent Care Reimbursement Accounts