Nurse Evaluator, Health Services Series

California State Personnel Board Specification

Series established December 6, 1972

Scope

This series specification describes the four professional nurse classifications used by the Department of Health Services and other State agencies. The series is used primarily in the Medi-Cal Operations Program of the Department of Health Services but is also appropriate for use in other programs or State agencies which monitor the services provided through various organized health systems.

Definition of Series

Nurse Evaluators, Health Services, are professional Nurses, licensed by the State of California who work for the Department of Health Services or other State agencies. Nurse Evaluators, Health Services, perform onsite evaluations of services and quality assurance reviews of facilities, detect and develop cases where fraud or abuse is suspected, monitor service provider claims, and conduct site reviews and audits. Nurse Evaluators, Health Services; are responsible for determining quality of care being received by program beneficiaries in health facilities and identifying levels of care to meet each beneficiary's health care needs; for monitoring medical services of providers; evaluating prior authorization requests for a variety of medical services; for training and supervising other staff in regulations and implementation of the Medi-Cal or other health care programs; for taking independent action within professional protocols and legal limits of the Medi-Cal or other health care program; and for assistance in analysis of the program and other related duties.

Factors Affecting Position Allocation

Level of difficulty, variety, and complexity of assigned duties; independence of action and decision; degree of supervision required and received; and degree of supervision exercised serve as differentiating factors between individual classes.

Definition of Levels

Nurse Evaluator I, Health Services

Under close supervision, the Nurse Evaluator I, Health Services, learns about the Medi-Cal or other health care program, and performs the more simple tasks as an onsite nurse or a member of a Medical Review Team; evaluates quality of nursing care of program beneficiaries; evaluates levels of care required by program beneficiaries; evaluates Treatment Authorization Requests for services; participates in annual reviews of facilities providing care and does other related work.

Nurse Evaluator II, Health Services

Under direction, the Nurse Evaluator II, Health Services, works as an onsite nurse or member of a Medical Review Team; evaluates quality of nursing care being received by program beneficiaries; evaluates levels of care required by program beneficiaries; evaluates Treatment Authorization Requests for services; participates in annual reviews of facilities providing care; assists in training of other staff; assists in evaluation of procedures, investigation of fraud and abuse, and enforcement of regulations; relieves Nurse Evaluator III/IV, Health Services as required.

Nurse Evaluator III, Health Services

Under direction a Nurse Evaluator III, Health Services is responsible for the overall scheduling and management of onsite reviews in an assigned area; is responsible for training and direct supervision of subordinate Nurse Evaluators, Health Services, production; plans, evaluates, and provides continuity of criteria used for recommendations of levels of care by staff; works with administration in evaluation and implementation of procedures in accordance with regulations; works with other disciplines and departments in follow-up of reports and recommendations of the Medical Review personnel and onsite nurses; supervises, evaluates, and reports statistics on staff production; teaches, plans, directs, coordinates, and evaluates personnel.

Nurse Evaluator IV, Health Services

Under direction, a Nurse Evaluator IV, Health Services, is responsible for the overall scheduling and management of onsite reviews in an assigned area; is responsible for training and direct supervision of a large staff comprised of both Nurse Evaluators, Health Services and Medical Consultants; plans, evaluates, and provides continuity of criteria used for recommendations of levels of care by staff; works with administration in evaluation and implementations of procedures in accordance with regulations; works with other disciplines and departments in follow-up of reports and recommendations of the medical review personnel and onsite nurses; supervises, evaluates, and reports statistics on staff production; teaches, plans, directs, coordinates and evaluates personnel.

Minimum Qualifications

All Levels:

Licensure Requirements: Possession of a valid license to practice as a professional registered nurse in California.

Nurse Evaluator I, Health Services

Two years of professional nursing experience in an institution licensed for inpatient care. (A Master's Degree in Nursing may be substituted for one year of experience, or a Baccalaureate Degree in Nursing may be substituted for six months of the required experience. One year of experience as Psychiatric Technician may be substituted for six months of the required experience.)

Nurse Evaluator II, Health Services

Either I

One year of experience performing duties of a Nurse Evaluator I, Health Services.

Or II

Three years of professional nursing experience in an institution licensed for inpatient care. (Possession of a Master's Degree in Nursing may be substituted for one year of the required experience.)

Nurse Evaluator III, Health Services

Either I

One year of experience performing the duties of a Nurse Evaluator II, Health Services.

Or II

Four years of professional nursing experience in an institution licensed for inpatient care, one year of which must have been at the supervising level. (Possession of a Master's Degree may be substituted for one year of the required experience.)

Nurse Evaluator IV, Health Services

Either I

One year of experience performing the duties of a Nurse Evaluator III, Health Services, or two years of experience performing the duties of a Nurse Evaluator II, Health Services.

Or II

Five years of professional nursing experience in an institution licensed for inpatient care, two years of which must have been at the supervising level. (Possession of a master's degree may be substituted for one year of the required experience.)

Knowledge and Abilities

All Levels:

Knowledge of: Professional nursing principles and techniques; medical terminology, hospital routine and equipment; and medicines and narcotics.

Ability to: Observe and record symptoms and patient behavior; document records and prepare reports; make independent recommendations on required levels of care for patients; follow regulations and outlined procedures; maintain good public relations with patients and providers of service; and work cooperatively with other Team members.

Nurse Evaluator Iii/IV, Health Services

Knowledge of: All of the above, and personnel management; analytical evaluation of procedure; and training and teaching techniques and techniques of effective supervision; Department's Affirmative Action Program objectives; a manager's role in the Affirmative Action Program and the processes available to meet affirmative action objectives.

Ability to: All of the above, and plan, organize, train, and supervise the work of others; effectively contribute to the Department's affirmative action objectives.

Special Personal Characteristics

All Levels:

Must possess aptitude for and willingness to work as Team members; emotional stability; sensitivity to patient's needs; patience; tact; alertness; and keenness of observation.

Class History