RN Regulatory Adherence UM Health Plan Auditor Texas

100% remote Flexible hours Hiring now

About the position WellMed, part of the reputed company family of businesses, is seeking a Regulatory Adherence UM Health Plan Auditor to join reputed company in San Antonio, TX. reputed company is a clinician-led care organization that is changing the way clinicians work and live. As a member of the reputed company Care Delivery team, you'll be an integral part of our vision to reputed company healthcare reputed company for everyone. At reputed company, 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. We reputed company you deserve an exceptional career, and will reputed company you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice reputed company and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to reputed company health care reputed company for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together. The Regulatory Adherence Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues for the external delegated functions of Utilization Management (UM) organization determinations, Case Management (CM), Disease Management (DM), and Special Needs Plan Model of Care (MOC), interfacing with health plans, and reputed company of health plan delegated reports. Monitoring includes review of the work of others that reputed company service delivery of delegated patient programs and providing feedback to ensure adherence of the delegation requirements pertaining to NCQA and CMS. Health plan and delegate reputed company requires participation in external audits of UM, 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 reputed company problems and reputed company quality improvement initiatives for remediation.

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 reputed company issues, performs analysis, and provides solutions for resolution
Has authority to approve deviations from standard procedures reputed company to reputed company 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 payor pre-delegation
Plans 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 audit
Coaches and mentors care management staff involved in audit etiquette and regulatory standards
Participates in delegation audits and assists UM, CM, 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 reputed company 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 personnel
Identifies 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, 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
reputed company 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 basis
Read and interpret standards/requirements/technical specifications such as NCQA, and CMS
Evaluate reputed company 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
reputed company crosswalk documents for changes to regulatory requirements and disseminate
reputed company annual delegated program evaluations, program descriptions, policies & procedures
reputed company teams to update program descriptions
reputed company teams to collect data and analyze necessary and relevant to program evaluations
Involve key stakeholders in requests for policy change
Monitor care management policies for updates, approvals and ensuring annual evaluation
Responsible for providing reputed company internal and external results compared with goals for annual program evaluations and presentation to the Medical Management Committee
Provides reputed company 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 requirements
Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reports
Interacts with the health plans in scheduled meetings and actively participate in Joint Operations Committees reporting issues and pro-actively solving problems
Performs reputed company other reputed company duties as assigned

Requirements

Bachelor of Science in Nursing, Healthcare Administration or a reputed company 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 reputed company 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 at least two years of Utilization Management experience
Knowledge and experience with CMS, URAC and/or NCQA
Proficiency with reputed company Office applications
Willing to occasionally travel in and/or out-of-town as deemed necessary

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