Clinical Quality Auditor

4 days ago


San Antonio, Texas, United States UnitedHealth Group Inc Full time
Clinical Quality Auditor Opportunity in San Antonio, Texas

We are seeking a skilled Clinical Quality Auditor to join our team at WellMed Healthcare in San Antonio, Texas. This is an exciting opportunity for a dedicated professional to make a meaningful impact on the quality of care provided to our patients.

Job Summary:

The Clinical Quality Auditor will be responsible for monitoring and reporting compliance issues related to Population Health Management, Complex Case Management, and Special Needs Plan Model of Care. This includes interfacing with health plans, oversight of health plan delegated reports, and ensuring adherence to NCQA and CMS guidelines.

Key Responsibilities:

  • Conduct audit reviews of Clinical Program documents to ensure accuracy and compliance with CMS, NCQA, and Health Plan requirements
  • Utilize audit tools to perform documentation audits on job functions within Clinical Programs
  • Perform regular audits to ensure data entry accuracy and compliance of required documentation
  • Communicate regular audit results to management and interface with managers, staff, and training to make recommendations on potential training needs or revisions in daily operations

Reporting Requirements:

  • 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 report

Additional Responsibilities:

  • 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

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, including experience in a managed care setting, 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

Salary: $85,000 - $110,000 per year, depending on experience

About Us:

WellMed Healthcare is a network of doctors, specialists, and medical professionals that specialize in providing care for older adults. We are innovators in preventative healthcare, striving to change the face of healthcare for seniors. Our focus is simple: we're making healthcare better for everyone.



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