Senior Clinical Quality RN
2 weeks ago
WellMed, part of the Optum family of businesses, is seeking a Senior Clinical Quality RN to join our team in a managed care setting. As a clinician-led care organization, we're 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. You'll have the clinical resources, data, and support of a global organization behind you so you can help your patients live healthier lives.
At Optum, 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 we'll empower you to live your best life at work and at home.
Under the direction of providers or RNs, you'll provide 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.
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.
Primary Responsibilities:
- Conducts audit reviews of Organization Determinations, Adverse Determinations, and Notice of Medicare Non-Coverage 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.
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.
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 healthcare, striving to change the face of healthcare 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 healthcare work better for everyone.
Diversity creates a healthier atmosphere: OptumCare 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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