RN Regulatory Adherence UM Health Plan Auditor Texas Position Available In Washington, Alabama

Job Description:

WellMed, part of the Optum family of businesses, is seeking aRegulatory Adherence UM Health Plan Auditor to join our team in SanAntonio, TX. Optum is a clinician-led care organization that ischanging the way clinicians work and live.

• As a member of the Optum Care Delivery team, you’ll be an integralpart of our vision to make healthcare better for everyone.
• At Optum, you’ll have the clinical resources, data and support of aglobal organization behind you so you can help your patients livehealthier lives.

Here, you’ll work alongside talented peers in acollaborative environment that is guided by diversity and inclusionwhile driving towards the Quadruple Aim. We believe you deserve anexceptional career, and will empower you to live your best life atwork and at home. Experience the fulfillment of advancing thehealth of your community with the excitement of contributing newpractice ideas and initiatives that could help improve care formillions of patients across the country. Because together, we havethe power to make health care better for everyone. Join us anddiscover how rewarding medicine can be while Caring. Connecting.

Growing together.

• The Regulatory Adherence Sr. Clinical Quality RN is responsible formonitoring and reporting compliance issues for the externaldelegated functions of Utilization Management (UM) organizationdeterminations, Case Management (CM), Disease Management (DM), andSpecial Needs Plan Model of Care (MOC), interfacing with healthplans, and oversight of health plan delegated reports.
• Monitoringincludes review of the work of others that perform service deliveryof delegated patient programs and providing feedback to ensureadherence of the delegation requirements pertaining to NCQA andCMS.
• Health plan and delegate interface requires participation inexternal audits of UM, CM, DM, and MOC programs, monitoringpolicies and procedures, and preparation and review of clinicalfiles.
• Delegated reporting functions include report preparation,validation, and submission of CMS quality reports as well as healthplan reports on programs and metrics according to delegationagreement.
• This position requires a subject matter expert who isable to provide innovative solutions to complex problems and leadquality improvement initiatives for remediation.
• If you are located in Texas, you will have the flexibility to workremotely
• as you take on some tough challenges.

•

Position Highlights & Primary Responsibilities:

Interfaces with health plans and acts as liaison for delegatedservices Reviews delegation agreements and has a clear understanding ofdelegated services and reporting requirements Anticipates plan requirements and proactively works onsolutions to meet requirements Serves as a resource for complex issues, performs analysis, andprovides solutions for resolution

• Has authority to approve deviations from standard proceduresrelated to complex issues Serves as the primary contact and delegation resource forhealth plans
• Informs and educates health plan personnel regarding regulatoryand accreditation standards
• Manages the external audit process end to end to includeroutine delegation as well as new payor pre-delegation
• Plans for external audits by forecasting resource requirementsand planning to ensure availability of key stakeholders and otherresource requirements Coordinates onsite visit and facilitates meetings and auditprocess
• Prepares and submits document requests and caseuniverses Prepares and audits file requests based on regulatory andaccreditation requirements in a timely manner to provide keystakeholders an opportunity to correct deficiencies before theaudit
• Coaches and mentors care management staff involved in auditetiquette and regulatory standards Participates in delegation audits and assists UM, CM, DMdepartments with supplying information as needed
• Guides and influences the audit process by ensuring thatauditors adhere to the scope of the audit Follows up on action items and attempts to supply all neededinformation during the audit Follows up on corrective action plans ensuring timely closure
• Prepares summary of audit activities and outcomes Monitors data collection tools and ensures updates occur asregulatory and accreditation changes occur Provides direction and expertise on regulatory andaccreditation standards to health plan personnel as well asinternal personnel Identifies gaps in audit findings versus internal performancefindings
• Fosters open communication with managers/directors by acting asa liaison between the Training Department(s) and the MedicalManagement Department(s) Identify and communicate with appropriate departments, teams,and key leadership on internal audit results and/ordeficiencies Identify and communicate gaps between CMS and NCQA requirementsand internal documentation audits to appropriate departments,teams, and key leadership Collect audit result data, prepare comparison reports tointernal performance standards, and identify risk•Collect additional data as needed to assist in gapclosure Analyze results, provide interpretation, and identify areas forimprovement•Develop and utilize effective methods for data collection andquality improvement Provide training to managers, medical directors, and staff onregulatory information by developing educational materials,providing educational in-services, and/ or on a one to one basis•Read and interpret standards/ requirements/ technicalspecifications such as NCQA, and CMS Evaluate current processes, compare to relevant standards orspecifications, and identify gaps in compliance orperformance Work cross-functionally, making recommendations or clarifyinginformation to assist in closing gaps•Develop crosswalk documents for changes to regulatoryrequirements and disseminate Oversee annual delegated program evaluations, programdescriptions, policies & procedures Lead teams to update program descriptions Lead teams to collect data and analyze necessary and relevantto program evaluations Involve key stakeholders in requests for policy change Monitor care management policies for updates, approvals andensuring annual evaluation Responsible for providing all internal and external resultscompared with goals for annual program evaluations and presentationto the Medical Management Committee Provides all required UM delegation reports to health plan Prepares reports including those that require manualentry Validates accuracy of reports prior to submission Submits reports timely according to health planrequirements Interfaces with IT and Care Management and provides directionregarding additional reports or changes to delegation reports•Interacts with the health plans in scheduled meetings andactively participate in Joint Operations Committees reportingissues and pro-actively solving problems•Performs all other related duties as assigned•In 2011, WellMed partnered with Optum to provide care to patientsacross Texas and Florida.

WellMed is a network of doctors,specialists and other medical professionals that specialize inproviding care for more than 1 million older adults with over16,000 doctors’ offices. At WellMed our focus is simple. We’reinnovators in preventative health care, striving to change the faceof health care for seniors. WellMed has

• more than 22,000+ primarycare physicians, hospitalists, specialists, and advanced practiceclinicians who excel in caring for 900,000+ older adults. Together,we’re making health care work better for everyone.
• You’ll be rewarded and recognized for your performance in anenvironment that will challenge you and give you clear direction onwhat it takes to succeed in your role as well as providedevelopment for other roles you may be interested in.

RequiredQualifications:

Bachelor of Science in Nursing, Healthcare Administration or arelated field (Eight additional years of comparable work experiencebeyond the required years of experience may be substituted in lieuof a bachelor’s degree) Registered Nurse (RN) with current license in Texas, or otherparticipating States 5+ years of progressively responsible healthcare experience toinclude experience in a managed care setting, and/or hospitalsettings, and/or physician practice setting

• 3+ years of experience in managed care with at least two yearsof Utilization Management experience
• 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 deemednecessary

• Preferred Qualifications:

• Health Plan or MSO quality, audit, or complianceexperience Previous auditing, training, or leadership experience Solid knowledge of Medicare and TDI regulatory standards

•

Values Based Competencies:

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

• All employees working remotely will be required to adhere toUnitedHealth Group’s Telecommuter Policy
• The salary range for this role is $71,600 to $140,600 annuallybased on full-time employment.

Pay is based on several factorsincluding but not limited to local labor markets, education, workexperience, certifications, etc. UnitedHealth Group complies withall minimum wage laws as applicable. In addition to your salary,UnitedHealth Group offers benefits such as, a comprehensivebenefits package, incentive and recognition programs, equity stockpurchase and 401k contribution (all benefits are subject toeligibility requirements). No matter where or when you begin acareer with UnitedHealth Group, you’ll find a far-reaching choiceof benefits and incentives.

• OptumCare is an Equal Employment Opportunity employer underapplicable law and qualified applicants will receive considerationfor employment without regard to race, national origin, religion,age, color, sex, sexual orientation, gender identity, disability,or protected veteran status, or any other characteristic protectedby local, state, or federal laws, rules, or regulations.
• OptumCare is a drug-free workplace.

Candidates are required to passa drug test before beginning employment.