Sr Nurse - Quality & Acc.

HealthHelp•Houston, TX

4d•Remote

About The Position

HealthHelp’s Senior Nurse - Quality and Accreditation is responsible for quality assurance activities that measure clinical review performance against client contract, regulatory, and accreditation requirements. The role identifies trends and root causes early so that issues can be corrected before they result in client escalations or corrective action plans. It involves internal and external quality auditing, regulatory subject matter expertise, process improvement, and cross-department collaboration and support. The position conducts and supports audits of clinical review activities, provides quality scoring and trend analysis, recommends and follows up on corrective actions, and helps prepare materials for client, accreditation, and regulatory audits. It also contributes to quality improvement projects and performs assigned non-auditing functions within Quality and Accreditation. The role must comply with applicable privacy, fraud prevention, consumer health and safety, and state and federal regulatory requirements. The position requires work from a HIPAA-compliant remote location with reliable high-speed internet. The base salary 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, conduct root cause analysis, and clearly present findings 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.
Fluency in English.
Excellent listening, oral, written, 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 in data collection, clinical review audits, and record maintenance.
Ability to recognize potential and actual problems and work with a team to develop solutions and implement effective action plans.
Ability to use a telephone, sit, enter data, and view a PC screen for up to 8 hours.
Ability to prioritize in a multitask environment.
Reliable high-speed internet and a HIPAA-compliant remote work location.

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.
Follow standardized processes for quality audits, including Interrater Reliability audits, audits of adverse determination notices and supporting documentation, and physician reviewer audits conducted with Medical Directors; recommend improvements to audit scope, sampling, and tools.
Meet the department’s audit accuracy standard and participate in audit calibration.
Provide quality scores and trends to Clinical Review management at individual and departmental levels, perform root cause analysis of negative trends, recommend corrective actions, and follow up to confirm implementation.
Promptly inform management of critical issues, with supporting facts and a recommended action.
Contribute audit findings and case examples to updates for Operations and Clinical Education.
Facilitate the development and implementation of Quality Improvement Projects.
Maintain working knowledge of utilization management workflows, systems, and policies for audited programs; complete operational workflow training and keep that knowledge current.
Report receipt date, notification date, and system timestamp discrepancies found during audits in accordance with 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.
Assist with compiling data for quarterly submission to the Quality Management Committee 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 mandatory education and training logs; credentialing clinical and other licensed contractors or employees; and maintaining OIG and SAM logs for clinical staff.
Adhere to HIPAA, FWA, Consumer Health and Safety, state and federal regulations, and HealthHelp policies and procedures.
Uphold professional standards, treat others respectfully, provide high-quality service and support to internal and external clients, and promote the company’s vision, mission, and strategy.
Perform other duties as assigned to meet business needs.