Lead Cap/C Nurse Consultant Ii

**This position is exempt from the State Human Resources Act**

This position was previously posted under exam plan 23-11772. Previous applicants must reapply to this posting if they wish to be considered.

TELEWORK AVAILABILITY: We trust our employees to be self-motivated and successful in hybrid/remote roles; NC Department of Health and Human Services offers work from home options and variable work schedule flexibility for this position.

Division of Health Benefits employees with an approved hybrid telework schedule are currently expected to work onsite at their assigned duty station at least 4 working days per month. More information on this arrangement may be obtained at the time of interview.

This position's duty station is assigned to Dix Campus in Raleigh, North Carolina.

Position Summary

Medicaid Long-Term Benefits and Supports (LTBS) programs serve individuals who are among North Carolina's most vulnerable citizens. The populations using LTBS are extremely diverse and range in age from 0 to death in terms of individuals' care needs, service utilization and spending. Long-Term Benefits and Supports (LTBS), as defined by the Centers for Medicare and Medicaid services, include care provided in the home, in community-based settings or in facilities, such as nursing homes; care for people of all ages with disabilities who need support because of age, physical, cognitive, developmental or chronic health conditions, or other functional limitations that restrict their abilities to care for themselves.

CAP/C is an NC Medicaid Home and Community-based Services (HCBS) program authorized under section 1915(c) of the Social Security Act and complies with 42 CFR § 440.180, Home and Community-based Waiver Services. The waiver program provides a cost-effective alternative to institutionalization for Medicaid beneficiaries who are medically fragile and at risk for institutionalization if the home and community-based services approved in the CAP/C waiver were not available. These services allow the beneficiary to remain in or return to a home and community-based setting. The waiver supplements, rather than replaces, the formal and informal services and supports already available to an approved Medicaid beneficiary. The CAP/C waiver is for medically fragile and medically complex individuals between the ages of 0 through 20.

The Lead CAP/C Nurse Consultant II reports to the CAP/C Unit Nurse Manager. The primary need for this position is to provide oversight, technical support, and auditing of two contracted vendors, local non-government entities, and service providers in program enrollment, utilization management, and expenditures against approved levels. This position also makes level-of-care evaluation decisions, conducts quality assurance reviews of service plans, and ensures providers are trained and qualified to render 1915 (c) services to medically fragile children. The Lead CAP/C Nurse Consultant II will also recommend revisions to rules, policies, and procedures from quality assurance and quality improvement activities.

Job Specific Responsibilities

• Serve as manager of the unit in the CAP/C Unit Nurse Manager's unavailability or absence.
• Ensure that Medicaid coverage of the Community Alternatives Program for Children (CAP/C) and the Community Alternatives Program for Disabled Adults CAP/DA) programs are in accordance with Federal and State laws, rules, and regulations, and DHB's goals and objectives.
• Conduct reviews of referrals to the CAP/C and CAP/DA programs.
• Perform accurate and consistent prior authorization reviews of all requested CAP/C waiver services within Due Process timelines through application of the current clinical coverage policy.
• Upon successful transition of the waiver enrollment and Case Management functions to the Comprehensive Independent Assessment Entity (CIAE), this position will be responsible for administrative and oversight functions related to Waiver Assurances to meet Federal requirements.
• Compose succinct and accurate adverse determination notices for distribution to beneficiaries and/or responsible parties.
• Participate in mediations and appeals procedures based on adverse program determinations.
• Provide clinical support and assistance to other home and community-based services programs within the LTSS nursing unit, CAP/DA, and Money Follows the Person (MFP) transitions.
• Collaborate with other members of the LTSS Nurse Unit in the development, implementation, and ongoing review of policies, procedures, and standards of care for designated programs.

Applicants are encouraged to apply for positions of interest, regardless of their current grade level and job classification. A pay increase may or may not result. Salary decisions are based on relevant education and experience, budget, and internal equity.

About NC Medicaid (Division of Health Benefits)

The North Carolina Department of Health and Human Services (NCDHHS) works closely with beneficiaries, health care professionals, community leaders and advocacy groups; local, state and federal entities; and other community partners vested to improve the health and safety of all North Carolinians by providing essential human services. NCDHHS is one of the largest, most complex agencies in the state, with about 17,000 employees.

The Division of Health Benefits (DHB) within NCDHHS is committed to advancing innovative solutions that improve health, promote well-being and foster independence for all North Carolinians. DHB manages and oversees North Carolina Medicaid, NC Medicaid Managed Care and other programs that provide access to services and supports for parents, children, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders. With a budget over $21 billion in state and federal funds per fiscal year, DHB ensures that more than 96,000 enrolled providers are reimbursed for delivering covered services to 2.9 million beneficiaries.

Realizing the strength of DHB lies in its employees, DHB remains dedicated in its efforts to create and maintain a diverse, equitable and inclusive workplace environment.

To receive credit for all of your work history and credentials, you must list the information on the application form. Any information listed under the text resume section or on an attachment will not be considered for qualifying credit. Qualified applicants must document on the application that they possess all of the following:

• Proven ability in establishing and maintaining effective working relationships.
• Excellent oral and written communication skills.
• Demonstrated ability to understand and translate complex medical and regulatory requirements into practical, clear and unambiguous policies and procedures.
• Analytical skills for program development and evaluation.
• Proven knowledge of medical terminology.
• In-depth knowledge of current principles, standards, and practices of nursing.
• Proficiency in Microsoft Office, including Outlook, Word, and Excel.

Management Preferences:

• Previous and proven work experience at Division of Health Benefits/NC Medicaid.
• Familiarity with relevant and current NC Medicaid operations.
• Previous experience as a nurse lead or supervisor, preferably in a home health or long-term care setting.
• Knowledge of Long-Term Care, Managed Care and Home and Community Based Services.
• Familiarity with NC TRACKS.
• Experience with case management of medically fragile children.
• Previous experience with the CAP/C program.
• Experience in quality improvement methodologies and quality management.

Some state job postings say you can qualify by an "equivalent combination of education and experience." If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See oshr.nc.gov/experience-guide for details.

Licensed to practice as a Registered Nurse in the State of North Carolina and two years of clinical experience in the area of specialization.

Degrees must be from appropriately accredited colleges or universities.

The North Carolina Department of Health and Human Services is an Equal Opportunity Employer.

Pre-employment criminal background checks are required for all positions with the Division of Health Benefits (DHB).

To be under consideration for this vacancy, all applicants must complete an online application using this link: https://www.governmentjobs.com/careers/northcarolina. If multiple applications are submitted to an individual posting, only the most recent application received prior to the posting close date will be evaluated for consideration.

Due to the volume of applications received, we are unable to provide information regarding the status of your application over the phone. To check the status of your application, please log in to your account. You will either receive a call to schedule an interview or an email notifying you when the job has been filled.

For technical issues with your application, please call the NeoGov Help Line at 855-524-5627. Applicants will be communicated with via email only for updates on the status of their application. If there are any questions about this posting other than your application status, please contact us at Medicaid.Recruitment@dhhs.nc.gov.