25 days old

Registered Nurse RN Clinical Quality Analyst WellMed San Antonio TX

San Antonio, TX 78205
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  • Job Code
    867404
  • Jobs Rated
    118th

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 achieve your life's best work.(sm)


The Regulatory Adherence Utilization Management (RA UM) Sr. Clinical Quality Analyst is responsible for monitoring and reporting compliance issues with Utilization Management (UM) Organization Determinations Appeals and Grievances for oversight of health plan delegated reports, and internal and external audits from vendors interfacing with health plans.  Monitoring includes ongoing audits, improvement actions and overall feedback on the process to ensure that Medical Management, (MM), UM and Inpatient Case Managers audit requirements pertaining to NCQA and CMS are met.  This position requires a current unrestricted nursing license (i.e. RN) in the applicable state, who is a subject matter expert and is able to provide innovative solutions to complex problems, oversees UM reporting functions, ensures accuracy through data validation and leads quality improvement initiatives for remediation. 


Primary Responsibilities:

  • Conducts audit reviews of Organization Determinations Appeals and Grievances (ODAG), Adverse Determinations, Notice of Medicare Non-Coverage documents (NOMNC) and Detailed Explanation of Non-Coverage (DENC) documents to assure accuracy and compliance with UM plan, CMS, NCQA, URAC and Department of Insurance guidelines
    Utilizes audit tools to perform documentation audits on job functions within Utilization Management.
    • Performs regular audits to ensure data entry accuracy
    • Performs regular audits to ensure Compliance of required documentation
    • Communicates regular audit results to management and interfaces with managers, staff and training to make recommendations on potential training needs or revision in daily operations
  • Reports on departmental functions to include, data entry accuracy and monthly trends of internal audits
    • Prepares monthly and/or quarterly summary report compiling data for all markets
    • Prepares monthly and/or quarterly detailed and trending employee report
      Participates in the development, planning, and execution of auditing processes
    • Fosters open communication with managers/directors by acting as a liaison
      between the Training Department(s), the Medical Management Department(s) and the Utilization Departments
    • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
    • Identifies and communicates gaps between CMS requirements and internal documentation audits to appropriate departments, teams, and key leadership
  • Manages and performs tasks related to annual audit review (or more frequent review as requested) for contracted health plans as well as pre-delegation review with potential health plans
    • Prepares and audits files for submission as required
    • Participates in RA-UM audits and assists business 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 as needed
    • Follows up on corrective action plans and improvement action plan ensuring timely closure
    • Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur
    • Provides direction and expertise on regulatory and accreditation standards to internal personnel
  • Coordinates with RA-UM Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, URAC, and Department of Insurance guidelines
    • Performs audit reviews including annual audits to evaluate policies, CMS compliance and adherence to RA-UM health plans with regular audits focusing on compliance with Organization Determination and Adverse Determination regulations
    • Demonstrate understanding necessary to assess, review and apply criteria (e.g., MCG guidelines, CMS criteria, medical policy, and health plan specific criteria.)
    • Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness pharmacy audit reviews
    • Prepares a summary report of each evaluation including any deficiencies. and corrective action plans
    • Provides regular follow-up with delegates for completion of corrective action plans and improvement action plans
    • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
  • Provides all required Regulatory Adherence - Utilization Management (RA-UM) reports to health plan
    • Validates accuracy of reports prior to submission
    • Submits reports timely according to health plan requirements
    • Analyze results, provide interpretation, and identify areas for improvement
    • Interfaces with IT and provides direction regarding additional reports or changes to RA-UM reports
  • Ensure Compliance with Relevant Processes, Procedures, and Regulations
    • Ensure compliance with accreditation requirements (e.g., NCQA, CMS) and relevant health plan requirements
    • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
    • Follow internal policies/procedures (e.g., job aids, medical policy and benefit documents)
    • Identifies and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership
    • Recognize when additional regulations may apply and research and collect additional data as needed to obtain relevant information
    • Analyze results, provide interpretation, and identify areas for improvement
    • Responsible for providing internal and external results compared with goals for annual program evaluations and presentation to the Medical Management and Utilization Management, and Clinical Education Departments
  • Performs all other related duties as assigned

This is an office based position. The office is located off of Network Blvd in San Antonio, TX, 78249 / Local and Non-Local travel is required as determined by the business


You'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.

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Jobs Rated Reports for Registered Nurse

Posted: 2020-03-13 Expires: 2020-04-12

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Registered Nurse RN Clinical Quality Analyst WellMed San Antonio TX

UnitedHealth Group
San Antonio, TX 78205

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Registered Nurse
118th2018 - Registered Nurse
Overall Rating: 118/220
Median Salary: $70,000

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