RN - Quality Audit Nurse Specialist - San Antonio, TX

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)
 
The Audit Nurse Specialist  is responsible for monitoring and reporting compliance issues for the external delegated functions of Case Management (CM), Disease Management (DM), and 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 that delegation requirements pertaining to NCQA and CMS are met. Health plan and delegate interface requires participation in external audits of CM, DM, 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 a subject matter expert who is able to provide innovative solutions to complex problems and lead quality improvement initiatives for remediation. 
 
Please note: This is a M-F office based position. The office is located off of Northwest Parkway in San Antonio, TX.
 
Primary Responsibilities:

Interfaces with health plans and acts as liaison for delegated services

Reviews delegation agreements and has a clear understanding of delegated services and reporting requirements
Anticipates plan requirements and proactively works on solutions to meet requirements
Serves as a resource for complex issues and performs analysis and provides solutions for resolution
Has authority to approve deviations from standard procedures related to complex issues
Serves as the primary contact and delegation resource for health plans
Informs and educates health plan personnel regarding regulatory and accreditation standards 
Manages the external audit process end to end to include routine delegation as well as new payor pre-delegation
Plans in advance for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirements.
Coordinates onsite visit and facilitates meetings and audit process
Prepares and submits document requests and case universes
Prepares and audits file requests based on regulatory and accreditation requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before the audit
Coaches and mentors care management staff involved in audit etiquette and regulatory standards 

Participates in delegation audits and assists CM and DM departments 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 during the audit
Follows up on corrective action plans ensuring timely closure
Prepares summary of audit activities and outcomes
Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur
Provides direction and expertise on regulatory and accreditation standards to health plan personnel as well as internal personnel
Identifies gaps in audit findings versus internal performance findings 

Fosters open communication with managers/directors by acting as a liaison between the Training Department(s) and the Medical Management Department(s)
Identify and communicate with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
Identify and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership
Collect audit result data and prepare comparison reports to internal performance standards and identify risk
Collect additional data as needed to assist in gap closure
Analyze results, provide interpretation, and identify areas for improvement
Develop and utilize effective methods for data collection and quality improvement
Provide training to managers, medical directors,  and staff on regulatory information by developing educational materials, providing educational inservices, and/ or on a one to one basis
Read and interpret standards/ requirements/ technical specifications such as NCQA, MOC, CMS

Evaluate current processes, compare to relevant standards or specifications and identify gaps in compliance or performance
Work cross-functionally, making recommendations or clarifying information to assist in closing gaps
Develop cross-walk documents for changes to regulatory requirements and disseminate
Oversee annual delegated program evaluations, program descriptions, policies & procedures

Lead teams to update program descriptions
Lead teams to collect data and analyze necessary and relevant to program evaluation
Involve key stakeholders in requests for policy change
Monitor care management policies for updates, approvals and ensuring annual evaluation
Responsible for providing all internal and external results compared with goals for annual program evaluations and presentation to the Medical Management Committee.
Provides all required UM delegation reports to health plan

Prepares reports including those that require manual entry
Validates accuracy of reports prior to submission
Submits reports timely according to health plan requirement
Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reports
Interacts with the health plans in scheduled meetings and actively participate in  Joint Operations Committees reporting issues and pro-actively solving problems
Performs all other related duties as assigned

Required Qualifications:


Bachelor of Science in Nursing, Healthcare Administration or a related field required.  (Eight 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 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 experience in managed care with at least 2 years of Utilization Management experience

Knowledge and experience with CMS, URAC and/or NCQA required.

Proficiency with Microsoft Office applications required.

Must be willing to occasionally travel in and/or out-of-town as deemed necessary.
Preferred Qualifications:

Health Plan or MSO quality, audit or compliance experience
Strong knowledge of Medicare and TDI regulatory standards
Previous auditing, training or leadership experience
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: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.
 
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
Job Keywords: audit, quality, compliance, disease management, case management, RN, Registered Nurse, CMS, URAC, NCQA, WellMed, UnitedHealth Group, UHG, UnitedHealthcare, UHC, San Antonio, TX, Texas