Registered Nurse RN Quality Auditor WellMed Healthcare San Antonio Texas

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The Regulatory Adherence Clinical Program Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues for the external delegated functions of Population Health Management (PHM), Complex Case Management (CCM), and Special Needs Plan Model of Care (MOC), interfacing with health plans, and oversight of health plan delegated reports.  Monitoring includes review of the work of others that perform service delivery of delegated patient programs and providing feedback to ensure adherence to delegation requirements pertaining to NCQA and CMS.  Health plan and delegate interface requires participation in external audits of CCM, PHM, and MOC programs, monitoring policies and procedures, and preparation and review of clinical files.  Delegated reporting functions include report preparation, validation, and submission of CMS quality reports as well as health plan reports on programs and metrics according to delegation agreement.  This position requires an unrestricted RN license in the applicable state, who is a subject matter expert able to provide innovative solutions to complex problems and lead quality improvement initiatives for remediation.  

Primary Responsibilities:

• Conducts audit reviews of Clinical Program documents to assure accuracy and compliance with CMS, NCQA, and Health Plan requirements guidelines
• Utilizes audit tools to perform documentation audits on job functions within Clinical Programs
  • Performs regular audits to ensure data entry accuracy
  • Performs regular audits to ensure Compliance of required documentation
  • Communicates regular audit results to management and interfaces with managers, staff and training to make recommendations on potential training needs or revision in daily operations
• Reports on departmental functions to include, data entry accuracy and monthly trends of internal audits
  • Prepares monthly and/ or quarterly summary report compiling data for all markets
  • Prepares monthly and/ or quarterly detailed and trending employee report
• Participates in the development, planning, and execution of auditing processes
  • Fosters open communication with managers/directors by acting as a liaison between the Training Department(s), the Enterprise Care and Value Department(s) and Clinical Programs
  • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
  • Identifies and communicates gaps between CMS, NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership
• Manages and performs tasks related to annual audit review (or more frequent review as requested) for contracted Health Plans as well as pre-delegation review with potential Health Plans
  • Prepares and audits files for submission as required
  • Participates in Regulatory Adherence Clinical Program audits and assists business with supplying information as needed
  • Guides and influences the audit process by ensuring that auditors adhere to the scope of the audit
  • Follows up on action items and attempts to supply all needed information as needed
  • Follows up on corrective action plans and improvement action plan ensuring timely closure
  • Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur
  • Provides direction and expertise on regulatory and accreditation standards to internal personnel
• Coordinates with RA Clinical Programs Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, and NCQA guidelines
  • Performs audit reviews including annual audits to evaluate policies, CMS compliance and adherence to RA Clinical Programs delegation with regular audits focusing on compliance with regulations
  • Demonstrate understanding necessary to assess, review and apply criteria (e.g., NCQA guidelines, CMS criteria, and health plan specific criteria)
  • Apply knowledge of pharmacological and case management protocol to determine appropriateness of case management process
  • Prepares a summary report of each evaluation including any deficiencies and corrective action plans
  • Provides regular follow-up with delegates for completion of corrective action plans and improvement action plans
  • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
• Ensure Compliance with Relevant Processes, Procedures, and Regulations
  • Ensure compliance with accreditation requirements (e.g., NCQA, CMS) and relevant health plan requirements
  • Follow internal policies/procedures (e.g., job aids, medical policy and benefit documents)
  • Identifies and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership
  • Recognize when additional regulations may apply, research, and collect additional data as needed to obtain relevant information
  • Analyze results, provide interpretation, and identify areas for improvement
  • Responsible for providing internal and external results compared with goals for annual program evaluations and presentation to the Medical Management and Utilization Management, and Clinical Education Departments
• Performs all other related duties as assigned

This is an office-based position near IH 10 W. The position is Hybrid and will require 3 days a week in-office.  

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Bachelor of Science in Nursing, Healthcare Administration or a related field (3+ additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
• Registered Nurse (RN) with current license in Texas, or other participating States
• 5+ years of progressively responsible healthcare experience to include experience in a managed care setting, and/or hospital settings, and/or physician practice setting
• 3+ years of experience in managed care with 2+ years of Case Management experience
• Knowledge and experience with CMS, URAC and/or NCQA
• Proficiency with Microsoft Office applications
• Willing to occasionally travel in and/or out-of-town as deemed necessary

Preferred Qualifications:

• Health Plan or MSO quality, audit or compliance experience
• Auditing, training or leadership experience
• Solid knowledge of Medicare and TDI regulatory standards

Physical & Mental Requirements:

• Ability to push or pull heavy objects using up to       pounds of force
• Ability to properly drive and operate a company vehicle

Values Based Competencies Employee

• Integrity Value: Act Ethically
  • Comply with Applicable Laws, Regulations and Policies
  • Demonstrate Integrity
• Compassion Value: Focus on Customers
  • 
    Identify and Exceed Customer Expectations
  • Improve the Customer Experience
• Relationships Value: Act as a Team Player
  • Collaborate with Others
  • Demonstrate Diversity Awareness
  • Learn and Develop
• Relationships Value: Communicate Effectively
  • Influence Others
  • Listen Actively
  • Speak and Write Clearly
• Innovation Value: Support Change and Innovation
  • Contribute Innovative Ideas
  • Work Effectively in a Changing Environment
• Performance Value: Make Fact-Based Decisions
  • Apply Business Knowledge
  • Use Sound Judgement
• Performance Value: Deliver Quality Results
  • Drive for Results
  • Manage Time Effectively
  • Produce High-Quality Work

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and 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.   

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.