Assesses, plans, implements and evaluates audit, quality and compliance programs for all Care Management programs and initiatives. This role is responsible for maintaining departmental compliance with state and federal health plan requirements, Medicare guidelines and NCQA standards. Facilitates implementation of new regulations in a timely manner; and assists in the development of policies and procedures, process metrics, data collection tools, and presentations of resultant data. This position is accountable for informing and educating the managerial staff and the nursing staff on clinical guidelines, management of departmental clinical workflow and operations. Additionally, this position will provide reports and analyses to senior management, will serve as a liaison with providers to ensure optimal customer service is provided by nursing staff, will serve as facilitator/leader for process improvement efforts and provide education for targeted areas.
- Bachelor of Science in Nursing, Healthcare Administration or Business Administration required. (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree).
- Must be a Registered Nurse (RN) with current license in Texas, or other participating States.
- 8 or more years of progressively responsible healthcare experience to include experience in a managed care setting, and/or hospital settings, and/or physician practice setting required.
- 3 or more years of quality improvement experience in managed care with at least 2 years of disease management experience required.
- Experience in project/risk management, from implementation through operational phases and in developing policies and procedures required.
- Knowledge and experience of NCQA required.
- Basic knowledge of reliability, maintainability, and risk management, including key terms and definitions, modeling, systems design, assessment tools and reporting required.
- Proficiency with Microsoft Office applications required.
- Must be willing to occasionally travel in and/or out-of-town as deemed necessary
- CPHQ (Certified Professional in Healthcare Quality)
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: RN, registered nurse, audit, quality, compliance, management, manager, managed care, WellMed, UnitedHealth Group, UnitedHealthcare, UHG, UHC, San Antonio, TX, Texas