RN Regulatory Adherence UM Health Plan Auditor Texas

UnitedHealth Group-posted 7 months ago
$71,600 - $140,600/Yr
Full-time • Mid Level
Remote • San Antonio, TX
Insurance Carriers and Related Activities
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WellMed, part of the Optum family of businesses, is seeking a Regulatory Adherence UM Health Plan Auditor to join our team in San Antonio, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum 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. We believe you deserve an exceptional career, and will empower 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 ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better 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 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 adherence of the delegation requirements pertaining to NCQA and CMS. Health plan and delegate interface 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 complex problems and lead quality improvement initiatives for remediation.

  • 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, 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 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 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 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
  • 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 basis
  • Read and interpret standards/requirements/technical specifications such as NCQA, and 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 crosswalk documents for changes to regulatory requirements and disseminate
  • Oversee 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 evaluations
  • 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 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 all other related duties as assigned
  • 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 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 Microsoft Office applications
  • Willing to occasionally travel in and/or out-of-town as deemed necessary
  • Health Plan or MSO quality, audit, or compliance experience
  • Previous auditing, training, or leadership experience
  • Solid knowledge of Medicare and TDI regulatory standards
  • Comprehensive benefits package
  • Incentive and recognition programs
  • Equity stock purchase
  • 401k contribution
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