Registered Nurse RN Quality Auditor WellMed Healthcare San Antonio Texas

About the position 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 Requirements • 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 • 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 2+ years of Case 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 deemed necessary Nice-to-haves • Health Plan or MSO quality, audit or compliance experience • Auditing, training or leadership experience • Solid knowledge of Medicare and TDI regulatory standards Benefits • Competitive salary • Health insurance • Retirement savings plan • Paid time off • Professional development opportunities Apply tot his job Apply tot his job Apply To this Job