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UnitedHealth Group: Registered Nurse Auditor/Utilization Management Wellmed – San Antonio Tx

UnitedHealth Group

This is a Contract position in San Antonio, TX posted November 20, 2020.

Do you have compassion and a passion to help others?

Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieveyour life’s best work.

(sm)WellMed provides concierge level medical care and service for seniors, delivered by physicians and clinic stat that understands and care about the patient’s health.

WellMed’s proactive approach focuses on prevention and the complete coordination of care for patients.

WellMed is now part of the Optum division under the greater UnitedHealth Group umbrella.TheRegistered Nurse RN Auditoris 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 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 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.Primary Responsibilities:Interfaces with health plans and acts as liaison for delegated servicesReviews delegation agreements and has a clear understanding of delegated services and reporting requirementsAnticipates plan requirements and proactively works on solutions to meet requirementsServes as a resource for complex issues and performs analysis and provides solutions for resolutionHas authority to approve deviations from standard procedures related to complex issuesServes as the primary contact and delegation resource for health plansInforms and educates health plan personnel regarding regulatory and accreditation standardsManages the external audit process end to end to include routine delegation as well as new payor pre-delegationPlans in advance for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirementsCoordinates onsite visit and facilitates meetings and audit processPrepares and submits document requests and case universesPrepares 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 standardsParticipates in delegation audits and assists UM, CM, DM departments with supplying information as neededGuides and influences the audit process by ensuring that auditors adhere to the scope of the auditFollows up on action items and attempts to supply all needed information during the auditFollows up on corrective action plans ensuring timely closurePrepares summary of audit activities and outcomesMonitors data collection tools and ensures updates occur as regulatory and accreditation changes occurProvides direction and expertise on regulatory and accreditation standards to health plan personnel as well as internal personnelIdentifies gaps in audit findings versus internal performance findingsFosters 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 deficienciesIdentify and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadershipCollect audit result data and prepare comparison reports to internal performance standards and identify riskCollect additional data as needed to assist in gap closureAnalyze results, provide interpretation, and identify areas for improvementDevelop and utilize effective methods for data collection and quality improvementProvide training to managers, medical directors, and staff on regulatory information by developing educational materials, providing educational inservices, and/ or on a one to one basisRead and interpret standards/ requirements/ technical specifications such as NCQA, MOC, CMSEvaluate current processes, compare to relevant standards or specifications and identify gaps in compliance or performanceWork cross-functionally, making recommendations or clarifying information to assist in closing gapsDevelop cross-walk documents for changes to regulatory requirements and disseminateOversee annual delegated program evaluations, program descriptions, policies & proceduresLead teams to update program descriptionsLead teams to collect data and analyze necessary and relevant to program evaluationsInvolve key stakeholders in requests for policy changeMonitor care management policies for updates, approvals and ensuring annual evaluationResponsible for providing all internal and external results compared with goals for annual program evaluations and presentation to the Medical Management CommitteeProvides all required UM delegation reports to health planPrepares reports including those that require manual entryValidates accuracy of reports prior to submissionSubmits reports timely according to health plan requirementsInterfaces 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 problemsPerforms all other related duties as assignedThis is an office based position located near Network Blvd., San Antonio, TX 78249You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:Bachelor of Science in Nursing.

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 setting3 years of experience in managed care with at least two years of Utilization Management experienceKnowledge and experience with CMS, URAC and/or NCQAProficiency with Microsoft Office applicationsMust be willing to occasionally travel in and/or out-of-town as deemed necessary.Preferred Qualifications:Health Plan or MSO quality, audit or compliance experienceStrong knowledge of Medicare and TDI regulatory standardsPrevious auditing, training or leadership experiencePhysical & Mental Requirements:Ability to lift up to 25 poundsAbility to sit for extended periods of timeAbility to stand for extended periods of timeAbility to use fine motor skills to operate office equipment and/or machineryAbility to receive and comprehend instructions verbally and/or in writingAbility to use logical reasoning for simple and complex problem solvingCareers 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 impacting350,000 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 doyour 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 employmentJob Keywords:RN, CMS, URAC and/or NCQA, auditing, Case Management, Utilization Management, Managed Care, Quality Assurance, San Antonio Texas