Registered Nurse RN Utilization Management Quality Auditor San Antonio Texas

Job Summary:

We are seeking a highly skilled Registered Nurse RN to join our team as a Utilization Management Quality Auditor in San Antonio, Texas. As a key member of our team, you will be responsible for monitoring and reporting compliance issues, ensuring adherence to regulatory standards, and providing clinical support functions to patients.

Responsibilities:

• Conducts audit reviews of Organization Determinations, Adverse Determinations, and Notice of Medicare Non-Coverage documents to ensure 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 and 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, including data entry accuracy and monthly trends of internal audits.
• Prepares monthly and/or quarterly summary reports compiling data for all markets.
• Prepares monthly and/or quarterly detailed and trending employee reports.
• 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.
• Demonstrates understanding necessary to assess, review, and apply criteria (e.g., MCG guidelines, CMS criteria, medical policy, and health plan-specific criteria).
• Applies knowledge of pharmacological and clinical treatment protocol to determine appropriateness of 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 plans.
• Validates accuracy of reports prior to submission.
• Submits reports timely according to health plan requirements.
• Analyzes results, provides interpretation, and identifies areas for improvement.
• Interfaces with IT and provides direction regarding additional reports or changes to RA UM reports.
• Ensures compliance with relevant processes, procedures, and regulations.
• Ensures compliance with accreditation requirements (e.g., NCQA, CMS) and relevant health plan requirements.
• Utilizes 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.
• Follows internal policies/procedures (e.g., job aids, medical policy, and benefit documents).
• Identifies and communicates gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership.
• Recognizes when additional regulations may apply, researches, and collects additional data as needed to obtain relevant information.
• Analyzes results, provides interpretation, and identifies areas for improvement.
• Provides 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.

Requirements:

• 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, including 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.

About Us:

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. We have 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.

Equal Employment Opportunity/Affirmative Action Employer:

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.

Drug-Free Workplace:

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