Senior Clinical Quality Auditor for Population Health Management

6 days ago


Boerne, Texas, United States Optum Full time
About the Role

We are seeking a highly skilled Senior Clinical Quality Auditor to join our team at Optum in San Antonio, Texas. As a key member of our Regulatory Adherence Clinical Program, you will be responsible for monitoring and reporting compliance issues related to Population Health Management (PHM), Complex Case Management (CCM), and Special Needs Plan Model of Care (MOC). Your expertise will ensure adherence to CMS, NCQA, and health plan requirements, guiding internal audits and providing feedback to colleagues.

Responsibilities
  • Conduct thorough audits of clinical program documents to guarantee accuracy and compliance with relevant regulations and guidelines.
  • Utilize specialized audit tools to perform documentation reviews and ensure data entry accuracy.
  • Perform regular audits to verify compliance with required documentation and identify areas for improvement.
  • Communicate findings to management, interfacing with staff, training teams, and other stakeholders to recommend potential training needs or operational revisions.
  • Report on departmental functions, including data entry accuracy and monthly trends of internal audits.
Requirements

To succeed in this role, you will need:

  • A Bachelor's degree in Nursing, Healthcare Administration, or a related field, or equivalent experience.
  • An active RN license in Texas or another participating state.
  • A minimum of 5 years of progressively responsible healthcare experience, including experience in managed care settings, hospitals, or physician practices.
  • 3+ years of Case Management experience, along with knowledge of CMS, URAC, and/or NCQA standards.
  • Proficiency with Microsoft Office applications.
What We Offer

In addition to your professional growth and development, we provide:

  • A competitive salary of $85,000 - $110,000 per year, depending on experience.
  • A comprehensive benefits package, including medical, dental, and vision insurance.
  • A retirement savings plan with company match.
  • Ongoing education and training opportunities.
  • A collaborative work environment with diverse perspectives and experiences.
About Us

Optum is a clinician-led care organization that prioritizes quality, innovation, and patient-centered care. Our commitment to excellence drives us to continually improve processes, services, and outcomes. As part of our team, you will contribute to shaping the future of healthcare and making a meaningful impact on patients' lives.



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