Registered Nurse RN Utilization Management Quality Auditor San Antonio Texas

WellMed, part of the Optum family of businesses, is seeking a Registered Nurse  to join our team in San Antonio, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.
As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.
At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.
Under the direction of providers (defined as an MD, DO, DPM, NP, or PA) or RNs, the LVN/LPN provides clinical support functions and professional nursing care to patients using established standards of clinical nursing care and procedures approved by the applicable state board of nursing.  Is an active member of the health care team to assess patients’ needs, provide input into the plan of care and implement prescribed interventions.
The Regulatory Adherence Utilization Management Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues, with Utilization Management (UM) organization determinations, both internal and external from vendors interfacing with health plans, and oversight of health plan delegated reports. Monitoring includes ongoing audits, improvement actions and overall feedback on the process to ensure adherence by Utilization Management (UM), and Inpatient Case Managers to requirements pertaining to NCQA and CMS. This position requires a current unrestricted nursing license (i.e. RN) in the applicable state, who is a subject matter expert and is able to provide innovative solutions to complex problems, oversees UM reporting functions, ensures accuracy through data validation and leads quality improvement initiatives for remediation.
Primary Responsibilities:

Conducts audit reviews of Organization Determinations, Adverse Determinations and Notice of Medicare Non-Coverage documents (NOMNC) and Detailed Explanation of Non-Coverage (DENC) documents to assure accuracy and compliance with UM health plan, CMS, NCQA, URAC and Department of Insurance guidelines
Utilizes audit tools to perform documentation audits on job functions within Utilization Management

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 Medical Management Department(s) and the Utilization Departments
Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
Identifies and communicates gaps between CMS 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 Utilization Management (RA UM) 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 UM Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, URAC, and Department of Insurance guidelines

Performs audit reviews including annual audits to evaluate policies, CMS compliance and adherence to RA UM health plans with regular audits focusing on compliance with Organization Determination and Adverse Determination regulations
Demonstrate understanding necessary to assess, review and apply criteria (e.g., MCG guidelines, CMS criteria, medical policy, and health plan specific criteria.)
Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness pharmacy audit reviews


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
Provides all required Regulatory Adherence Utilization Management (RA UM) reports to health plan

Validates accuracy of reports prior to submission
Submits reports timely according to health plan requirements
Analyze results, provide interpretation, and identify areas for improvement
Interfaces with IT and provides direction regarding additional reports or changes to RA UM reports


Ensure Compliance with Relevant Processes, Procedures, and Regulations

Ensure compliance with accreditation requirements (e.g., NCQA, CMS) and relevant health plan requirements
Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
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
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 located near Interstate Highway I-10 West, near West Frontage Road just past The Rim Shopping Center/Ferrari Dealership, 78257

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 (Associate Degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor's degree)
Current unrestricted 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 at least 2+ years of Utilization Management experience
Knowledge and experience with CMS, URAC and NCQA
Knowledge of Medicare and Medicaid benefit products including applicable state regulations
Knowledge of computer functionality navigation and proficiency with Microsoft Office applications required (e.g., Windows, Microsoft Office applications including Microsoft Word and Microsoft Excel)
Knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims databases)
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
Solid knowledge of process flow of UM including prior authorization and/or clinical appeals and grievance reviews


Physical & Mental Requirements:

Ability to push or pull heavy objects 
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




In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
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.