Clinical Quality RN
5 days ago
Optum, a clinician-led care organization, is seeking a Registered Nurse to join our team in San Antonio, TX.
As a member of our 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.
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.
Under the direction of providers 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 healthcare 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.
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.
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.
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 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.
Participates in Regulatory Adherence Utilization Management (RA UM) audits and assists business with supplying information as needed.
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.
Provides all required Regulatory Adherence Utilization Management (RA UM) reports to health plan.
Submits reports timely according to health plan requirements.
Provides input into the plan of care and implements prescribed interventions.
Identifies and communicates 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.
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.
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.
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).
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.
Health Plan or MSO quality, audit, or compliance experience.
Auditing, training, or leadership experience.
Solid knowledge of Medicare and TDI regulatory standards.
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