Sr Nurse - Quality & Acc.

WNS Global Services•Houston, TX

8h•$80,000 - $90,000•Remote

About The Position

HealthHelp’s Senior Nurse - Quality and Accreditation conducts quality assurance activities to measure clinical review performance against client contract, regulatory, and accreditation requirements. The role identifies trends and root causes early so issues can be corrected before they result in client escalations or corrective action plans. It includes internal and external quality auditing, subject matter expertise on regulatory standards, process improvement, and cross-department collaboration and support. The position audits clinical review activities, reports quality scores and trends, analyzes root causes, and recommends and follows up on corrective actions. It also supports quality improvement projects, regulatory and accreditation audits, policy updates, committee reporting, and assigned non-auditing Quality and Accreditation functions. The role requires maintaining current knowledge of utilization management workflows, systems, policies, and applicable regulatory requirements while providing service and support to internal and external clients. This is a remote position requiring a HIPAA-compliant work location and reliable high-speed internet. The base salary range is $80,000–$90,000 annually. The role may also be eligible for performance-based bonuses, incentive pay, or commissions.

Requirements

Graduate of an accredited school of nursing.
Active, unrestricted RN license in a U.S. state or territory.
At least 3 years of utilization management experience at a health plan, utilization management vendor, or delegated utilization management organization.
At least 1 year of quality audit, quality assurance, or compliance audit experience.
Working knowledge of CMS coverage requirements (NCD and LCD) and applicable state requirements; ability to learn and apply HealthHelp proprietary clinical guidelines; and working knowledge of URAC and NCQA utilization management standards and Medicare Advantage, Medicaid, and commercial decision and notification requirements.
Ability to identify trends in audit data, complete root cause analyses, and present findings clearly in writing.
Ability to work independently, meet deadlines, and apply feedback and training in practice.
Proficiency in Microsoft Office, including Excel for sorting, filtering, and summarizing audit data.
Fluent English-speaking ability.
Excellent listening, oral, written communication, and presentation skills.
Strong problem-solving, interpersonal, and customer-service skills in face-to-face and remote settings.
Strong critical-thinking skills.
Ability to manage multiple projects simultaneously and prioritize work to meet changing deadlines.
Ability to collaborate with team members on data collection, clinical review audits, and record maintenance.
Ability to recognize actual and potential problems and work effectively with a team to develop solutions and implement action plans.
Access to a HIPAA-compliant remote location with reliable high-speed internet.
Ability to use a telephone, sit, enter data, and view a PC screen for up to 8 hours.
Ability to prioritize in a multitasking environment.

Nice To Haves

Three years of experience in an acute care setting.

Responsibilities

Conduct quality assurance reviews of clinical review departmental activities for compliance with regulatory requirements, client contracts, and URAC and NCQA accreditation standards.
Conduct standardized audits of clinical review activities, including Interrater Reliability audits, adverse determination notices and supporting documentation, and physician reviewer audits with Medical Directors; recommend improvements to audit scope, sampling, and tools.
Meet the department audit accuracy standard and participate in audit calibration.
Provide individual and departmental quality scores and trends to Clinical Review management; perform root cause analyses of negative trends, recommend corrective actions, and follow up to confirm implementation.
Promptly notify management of critical issues and provide supporting facts and recommended actions.
Contribute audit findings and case examples to Operations and Clinical Education updates.
Facilitate the development and implementation of Quality Improvement Projects.
Maintain and update working knowledge of utilization management workflows, systems, and policies for audited programs; complete operational workflow training.
Report receipt-date, notification-date, and system-timestamp discrepancies found during audits according to the data integrity policy.
Research potential fraud, waste, and abuse ordering patterns identified during review and compile cases for the manager.
Prepare case files, evidence, and written responses for client delegation audits, accreditation surveys, and regulatory audits.
Review operational policies and procedures against audit findings and requirement changes, and draft recommended updates for the manager.
Help compile data for quarterly Quality Management Committee submissions and ensure performance standards are measured and reported according to regulatory requirements.
Serve as backup for the manager on assigned deliverables when designated and share audit methods with peers.
Perform assigned non-auditing Quality and Accreditation functions, including handling complaints; maintaining required education and training logs; credentialing clinical and other licensed contractors or employees; and maintaining OIG and SAM logs for clinical staff.
Comply with HIPAA, FWA, Consumer Health and Safety, state and federal regulations, and HealthHelp policies and procedures.
Uphold professional standards, treat others respectfully, provide service and support to internal and external clients, and promote understanding of the company’s vision, mission, and strategy.
Perform other duties as assigned to meet business needs.

Benefits

Medical insurance
Dental insurance
Vision insurance
Paid time off (PTO)
Paid holidays
Sick leave
401(k) with company match or other retirement plan
Life and AD&D insurance
Employee Assistance Program
Potential eligibility for performance-based bonuses, incentive pay, or commissions