Nurse Specialist II

DC Government; Washington (District of Columbia); On-site; USD 90,000 - 110,000; Full time

Job summary

DC Government is seeking a healthcare professional to join the Department of Health Care Finance (DHCF) LTCA team. The role focuses on evidence-based LTSS acuity and medical necessity determinations for Medicaid LTSS programs, including HCBS, ICF/IID, and nursing facilities.

The incumbent will develop criteria, analyze trends, and present findings to leadership. The position requires a nursing license in the District of Columbia, appropriate degree, and experience in specialized LTSS settings.

Responsibilities

• Performs LTSS acuity and medical necessity determinations for Medicaid LTSS programs.
• Develops and updates criteria in line with clinical best practices and regulatory standards.
• Conducts risk stratification, quality audits, and analyzes service utilization across HCBS, ICF/IID, nursing facilities, and managed LTSS programs.
• Prepares and presents information via written documents, oral reports, and briefings.
• Collaborates with vendors, providers, and stakeholders; provides education and technical assistance.

Job description

When you become a member of Team DHCF (Department of Health Care Finance), the state Medicaid agency for the District of Columbia, you join our "Mission Possible!" We work every day, in concert with various District government agencies, to streamline access to comprehensive, affordable, and quality healthcare services for District residents. Whatever your position within our agency, you will positively impact beneficiaries, their families, and their future! We invite you to bring your skills, your experience and your passion to a job that makes a difference!

Job Summary

This position is located in the Department of Health Care Finance (DHCF), Long Term Care Administration (LTCA). The mission of DHCF is to ensure that comprehensive, cost-effective, quality healthcare services are provided for all residents of the District of Columbia ("District") who qualify for Medicaid or the Alliance (uninsured program for the District of Columbia residents).

Duties and Responsibilities

Conducts evidence-based LTSS acuity and medical necessity determinations. Develops, updates, and maintains evidence-based acuity and medical necessity criteria for Medicaid LTSS, ensuring alignment with clinical best practices and regulatory standards. Performs risk stratification analyses and quality audits for all Medicaid LTSS population, programs, and service delivery, including home and community-based services (HCBS), ICF/IID, and nursing facility, and managed LTSS programs to identify social determinants of health, evaluate service utilization, monitor use patterns to ensure appropriate, cost-effective care delivery, address over- or under-utilization of services, and recommend improvements for Medicaid LTSS programs. Analyzes and organizes clinical data, including trends across programs and population subgroups. Analyzes provider practice patterns, and clinical cases. Prepares and presents information using written documents, oral reports, and briefings on various clinical and programmatic health care topics. Coordinates and communicates with Medicaid LTSS vendors and contractors, providers, and Medicaid stakeholder groups. Provides education instruction, technical assistance, and training to beneficiary advocates and healthcare providers in the District.

Develops or employs systems and reports to store and access clinical information collected during routine oversight and operation of Medicaid LTSS, including EPD Waiver and State plan Medicaid programs. Receives, prepares, and submits cases and consults with review organizations serving Medicaid beneficiaries. Collaborates with other internal and external health care professionals and service providers to ensure optimal health care based on trends in complaints, grievances, appeals, and industry standards. Engages in advanced problem-solving to address policy challenges, formulates and updates Medicaid policies and regulations, and provides evidence-based recommendations to administration leadership on critical issues and strategic policy matters. Serves as the clinical lead in committees and workgroups, overseeing the monitoring of operations and providing guidance on the clinical oversight of all LTSS contracts, Memoranda of Understanding (MOUs), and regulatory mandates. Works closely with other DHCF personnel in conducting quality improvement initiatives and activities that support the delivery of programs and services to District residents. Develops policies and procedures, informational brochures, and other educational materials for distribution for information-sharing and public outreach.

Qualifications and Education

A graduate or higher level degree, bachelor’s degree, associate degree, or diploma from an accredited professional nursing educational program is required. This education must have been accredited by the Commission on Collegiate Nursing Education, Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained.

And

Specialized Experience – Experience that equipped the applicant with the particular knowledge, skills and abilities to perform successfully the duties of the position, and this is typically in or related to the work of the position to be filled.To be creditable, at least one (1) year of specialized experience must have been equivalent to at least the next lower grade level in the normal line of progression.

Licenses and Certifications

Must have a current license as a Registered Nurse in the District of Columbia.

This position requires that the incumbent possess and maintain a valid motor vehicle driver's license.

Working Conditions/Environment

The work is primarily performed in a typical office setting but may also involve field visits.

Other Significant Facts

Tour of Duty: Monday - Friday, 8:15 AM to 4:45 PM

Pay Plan, Series and Grade: CS-0610-12

Promotion Potential: No known promotion potential

Collective Bargaining Unit: This position is represented by a collective bargaining unit and is subject to union dues through payroll deduction.

Position Designation

The position has been deemed protection-sensitive. Accordingly, the incumbent will be subject to pre-employment checks (criminal background checks, consumer credit check, traffic record checks, if applicable) as a condition of employment, and will be subject to periodic criminal background checks for the duration of your tenure.

EEO Statement:

The District of Columbia Government does not discriminate or retaliate in employment on the basis of race, color, religion, sex, pregnancy, gender identity and expression, national origin, family responsibilities, political affiliation, sexual orientation, marital status, homeless status, disability, genetic information, age, membership in an employee organization, participation in a legally protected activity, parental status, matriculation, personal appearance, credit information, status as a victim or family member of a victim of domestic violence, sexual offense, or stalking, military service, or other non-merit factor.