There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm) **Please note: This is a M-F office based position. The office is located off of Northwest Parkway in San Antonio, TX** The Audit Nurse Specialist is responsible for monitoring and reporting compliance issues for the external delegated functions of Case Management (CM), Disease Management (DM), and Model of Care (MOC), interfacing with health plans, and oversight of health plan delegated reports. Monitoring includes review of the work of others that perform service delivery of delegated patient programs and providing feedback to ensure that delegation requirements pertaining to NCQA and CMS are met. Health plan and delegate interface requires participation in external audits of CM, DM, and MOC programs, monitoring policies and procedures, and preparation and review of clinical files. Delegated reporting functions include report preparation, validation, and submission of CMS quality reports as well as health plan reports on programs and metrics according to delegation agreement. This position requires a subject matter expert who is able to provide innovative solutions to complex problems and lead quality improvement initiatives for remediation. Primary Responsibilities:Interfaces with health plans and acts as liaison for delegated services Reviews delegation agreements and has a clear understanding of delegated services and reporting requirements Anticipates plan requirements and proactively works on solutions to meet requirements Serves as a resource for complex issues and performs analysis and provides solutions for resolution Has authority to approve deviations from standard procedures related to complex issues Serves as the primary contact and delegation resource for health plans Informs and educates health plan personnel regarding regulatory and accreditation standards Manages the external audit process end to end to include routine delegation as well as new payer pre-delegation Plans in advance for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirements. Coordinates onsite visit and facilitates meetings and audit process Prepares and submits document requests and case universes Prepares and audits file requests based on regulatory and accreditation requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before the auditCoaches and mentors care management staff involved in audit etiquette and regulatory standards Participates in delegation audits and assists CM and DM departments 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 during the audit Follows up on corrective action plans ensuring timely closure Prepares summary of audit activities and outcomes Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur Provides direction and expertise on regulatory and accreditation standards to health plan personnel as well as internal personnelIdentifies gaps in audit findings versus internal performance findings Fosters open communication with managers / directors by acting as a liaison between the Training Department(s) and the Medical Management Department(s) Identify and communicate with appropriate departments, teams, and key leadership on internal audit results and / or deficiencies Identify and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership Collect audit result data and prepare comparison reports to internal performance standards and identify risk Collect additional data as needed to assist in gap closure Analyze results, provide interpretation, and identify areas for improvement Develop and utilize effective methods for data collection and quality improvement Provide training to managers, medical directors, and staff on regulatory information by developing educational materials, providing educational in-services, and / or on a one to one basisRead and interpret standards / requirements / technical specifications such as NCQA, MOC, CMS Evaluate current processes, compare to relevant standards or specifications and identify gaps in compliance or performance Work cross-functionally, making recommendations or clarifying information to assist in closing gaps Develop cross-walk documents for changes to regulatory requirements and disseminateOversee annual delegated program evaluations, program descriptions, policies & procedures Lead teams to update program descriptions Lead teams to collect data and analyze necessary and relevant to program evaluation Involve key stakeholders in requests for policy change Monitor care management policies for updates, approvals and ensuring annual evaluation Responsible for providing all internal and external results compared with goals for annual program evaluations and presentation to the Medical Management Committee.Provides all required UM delegation reports to health plan Prepares reports including those that require manual entry Validates accuracy of reports prior to submission Submits reports timely according to health plan requirement Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reportsInteracts with the health plans in scheduled meetings and actively participate in Joint Operations Committees reporting issues and pro-actively solving problems Performs all other related duties as assigned
Required Qualifications: Bachelor of Science in Nursing, Healthcare Administration or a related field (Eight 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 States5+ 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 experienceKnowledge and experience with CMS, URAC and / or NCQA Proficiency with Microsoft Office applications Must be willing to occasionally travel in and / or out-of-town as deemed necessaryPreferred Qualifications:Health Plan or MSO quality, audit or compliance experience Strong knowledge of Medicare and TDI regulatory standards Previous auditing, training or leadership experienceCareers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group 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. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: WellMed, Healthcare, Bilingual, Registered Nurse, RN, Clinical Quality Specialist, Utilization Management, UM, URAC/NCQA regulations, managed care, transition planning/complex care case management, San Antonio, New Braunfels, Seguin, Gonzales, Shiner, Yoakum, Boerne, Floresville, Helotes, 78249,Texas, TX
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.