15 days old

VP Quality Improvement Regulatory Adherence Texas

San Antonio, TX 78205
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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)

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.

The primary responsibility of the VP, Quality Improvement Regulatory Adherence (UM, CM, DM, SNP) is to direct, plan, implement, and evaluate compliance activities related to Medical Management delegated functions. The VP facilitates implementation of new regulations in a timely manner and ensures that departmental maintain continuous compliance with health plan, state and federal requirements (i.e. CMS, URAC, NCQA standards and the Department of Insurance guidelines). This position oversees internal performance monitoring processes and coordinates delegation activities with the internal operational UM teams.

Primary Responsibilities:

  • Directs activities to ensure that department adheres to all regulations, contractual agreements, and applicable CMS, SNP, NCQA, URAC and other accreditation standards as well as internal policies related to regulatory or oversight agencies.
    • Coordinates and activates preparation activities for MSO and health plan audits for UM, CM, DM and SNP  MOC functions (i.e. CMS/NCQA SNP uploads, CMS Data Validation).
    • Identifies and communicates with appropriate teams on regulatory notifications, audit results and/or deficiencies.
  • Oversees, coordinates and ensures delegated partners adhere to all regulations, contractual agreements, and CMS, SNP, NCQA, URAC and other applicable accreditation standards.
    • Coordinates and activates preparation activities for contracted delegated entities where we perform designated UM, CM, DM and/or SNP MOC functions.
    • Oversees auditing and monitoring activities with delegated partners annually and as required.
    • Communicates with delegation teams on regulatory notifications, audit results and/or deficiencies.
  • Oversees monthly, quarterly and annual reporting activities with delegated partners, health plan and regulatory agencies to comply with continuous tracking and monitoring requirements.
  • Plans, directs, communicates, and executes internal quality assurance and performance auditing processes to assess UM, CM, DM and SNP MOC compliance with documentation requirements and as needed for improvement strategies in preparation for regulatory visits.
    • Oversees the development of appropriate audit tools to use.
    • Ensures systematic methodologies are utilized for audit processes. 
    • Develops and directs feedback processes for employees and managers on internal audit results.
    • Develops and directs reporting processes to track and trend internal results.
  • Evaluates effectiveness of auditing processes by assessing result trends over time, and recommends strategies for ongoing improvement efforts.
  • Provides guidance for development of training modules in conjunction with the business units and training teams, and as needed, delivers training to staff on regulatory topics impacting compliance activities.
  • Monitors compliance and compiles materials needed to file with applicable Department of Insurance (TDI) or other UR agency for licensure / certification in states where required.
  • Provides consistent application of policies and practices, feedback and direction for staff and team to ensure cohesive department growth and individual development.
  • Performs all other related duties as assigned.

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.

Posted: 2020-03-21 Expires: 2020-04-21

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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VP Quality Improvement Regulatory Adherence Texas

UnitedHealth Group
San Antonio, TX 78205

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