Senior Clinical Quality Auditor

5 days ago

San Antonio, Texas, United States UnitedHealth Group Inc Full time
Job Title: Senior Clinical Quality Auditor

WellMed, a part of the Optum family of businesses, is seeking a Senior Clinical Quality Auditor to join our team in San Antonio, Texas. As a clinician-led care organization, we are changing the way clinicians work and live.

Job Summary:

The Senior Clinical Quality Auditor is responsible for monitoring and reporting compliance issues for the external delegated functions of Population Health Management (PHM), Complex Case Management (CCM), and Special Needs Plan Model of Care (MOC). This includes interfacing with health plans and oversight of health plan delegated reports. The successful candidate will have a strong background in quality assurance and a proven track record of improving clinical outcomes.

Key Responsibilities:

  • Conducts audit reviews of Clinical Program documents to assure accuracy and compliance with CMS, NCQA, and Health Plan requirements guidelines
  • Utilizes audit tools to perform documentation audits on job functions within Clinical Programs
  • 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
  • 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 Enterprise Care and Value Department(s), and Clinical Programs
  • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
  • 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 Clinical Program 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 Clinical Programs Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, and NCQA guidelines
  • Performs audit reviews including annual audits to evaluate policies, CMS compliance and adherence to RA Clinical Programs delegation with regular audits focusing on compliance with regulations
  • Demonstrate understanding necessary to assess, review, and apply criteria (e.g., NCQA guidelines, CMS criteria, and health plan specific criteria)
  • Apply knowledge of pharmacological and case management protocol to determine appropriateness of case management process
  • 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

Requirements:

  • Bachelor of Science in Nursing, Healthcare Administration, or a related field (3+ additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor's degree)
  • 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 2+ years of Case Management experience
  • Knowledge and experience with CMS, URAC, and/or NCQA
  • Proficiency with Microsoft Office applications
  • 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

Physical & Mental Requirements:

  • Ability to push or pull heavy objects using pounds of force
  • 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

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