Opportunities at WellMed , part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind *Caring. Connecting. Growing together.  *

　　The Regulatory Adherence Clinical Program Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues for the external delegated functions of Population Health Management (PHM), Complex Case Management (CCM), and Special Needs Plan 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 adherence to delegation requirements pertaining to NCQA and CMS. Health plan and delegate interface requires participation in external audits of CCM, PHM, 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 an unrestricted RN license in the applicable state, who is a subject matter expert able to provide innovative solutions to complex problems and lead quality improvement initiatives for remediation.

　　Primary Responsibilities:

　　Conducts audit reviews of Clinical Program documents to assure accuracy and compliance with CMS, NCQA, and Health Plan requirements guidelines

　　Utilizes audit tools to perform documentation audits on job functions within Clinical Programs

　　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 Enterprise Care and Value Department(s) and Clinical Programs

　　Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies

　　Identifies and communicates gaps between CMS, NCQA 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 Regulatory Adherence Clinical Program 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 Clinical Programs Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, and NCQA guidelines .

　　Performs audit reviews including annual audits to evaluate policies, CMS compliance and adherence to RA Clinical Programs delegation with regular audits focusing on compliance with regulations

　　Demonstrate understanding necessary to assess, review and apply criteria (e.g., NCQA guidelines, CMS criteria, and health plan specific criteria.)

　　Apply knowledge of pharmacological and case management protocol to determine appropriateness of case management process

　　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

　　Ensure Compliance with Relevant Processes, Procedures, and Regulations

　　Ensure compliance with accreditation requirements (e.g., NCQA, CMS) and relevant health plan requirements

　　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, 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 located near Interstate Highway I-10 West, near West Frontage Road just past The Rim Shopping Center/Ferrari Dealership, 78257

　　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.

　　Required Qualifications:

　　Bachelor of Science in Nursing, Healthcare Administration or a related field (3+ 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 States

　　Knowledge and experience with CMS, URAC and/or NCQA

　　Proficiency with Microsoft Office applications

　　Willing to occasionally travel in and/or out-of-town as deemed

　　Preferred Qualifications:

　　5+ years of progressively responsible healthcare experience to include experience in a managed care setting, and/or hospital settings, and/or physician practice setting

　　3+ years of experience in managed care with at least 2+ years of Case Management experience

　　Health Plan or MSO quality, audit or compliance experience

　　Auditing, training or leadership experience

　　Solid knowledge of Medicare and TDI regulatory standards

　　Physical & Mental Requirements:

　　Ability to push or pull heavy objects using up to pounds of force

　　Ability to properly drive and operate a company vehicle

　　Values Based Competencies Employee

　　Integrity Value: Act Ethically

　　Comply with Applicable Laws, Regulations and Policies

　　Demonstrate Integrity

　　Compassion Value: Focus on Customers

　　Identify and Exceed Customer Expectations

　　Improve the Customer Experience

　　Relationships Value: Act as a Team Player

　　Collaborate with Others

　　Demonstrate Diversity Awareness

　　Learn and Develop

　　Relationships Value: Communicate Effectively

　　Influence Others

　　Listen Actively

　　Speak and Write Clearly

　　Innovation Value: Support Change and Innovation

　　Contribute Innovative Ideas

　　Work Effectively in a Changing Environment

　　Performance Value: Make Fact-Based Decisions

　　Apply Business Knowledge

　　Use Sound Judgement

　　Performance Value: Deliver Quality Results

　　Drive for Results

　　Manage Time Effectively

　　Produce High-Quality Work

　　At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

　　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 employment.