1+ months

Clinical Quality RN - WellMed - Telecommute Regionally near San Antonio, TX

San Antonio, TX 78205 Work Remotely
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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)

The Clinical Quality RN is responsible for monitoring and reporting compliance issues for the internal and external delegated functions of Utilization Management (UM) organization determinations, Case Management (CM), Disease Management (DM), and Model of Care (MOC), interfacing with health plans, WellMed delegates, and health plan delegated reports.  Monitoring includes ongoing internal performance audits with improvement actions and overall feedback on the process to ensure that delegation requirements pertaining to NCQA and CMS are met.  Health plan and delegate interface requires participation in external audits of UM, CM, DM, and MOC programs, policies, and 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. 

**Telecommuters must reside within 100 miles of San Antonio**

Primary Responsibilities:
  • Conducts review of UM, CM and DM cases to assure accuracy and compliance with UM plan, CMS, NCQA, and Department of Insurance guidelines. 
  • Utilizes audit tools to perform documentation audits on job functions within Care Management
    • Performs regular audits to ensure data entry accuracy.
    • Performs regular audits to ensure Compliance with 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) and the Medical Management Department(s).
    • Identify and communicate with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies.
    • Identify and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership.
  • Manages and performs tasks related to external audits from contracted health plans as well as pre-delegation review with potential health plans. 
    • Prepares and audits files for submission as required.
    • Participates in delegation audits and assists business with supplying information as needed.
    • Follows up on corrective action plans ensuring timely closure.
  •  Coordinates with UM Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, and Department of Insurance guidelines.
    •  Performs at least annual audits to evaluate policies, CMS compliance and adherence to UM plan with regular audits focusing on compliance with favorable and adverse organization determinations regulations. 
    • 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. 
  •  Provides all required UM delegation reports to health plan. 
    • Prepares reports including those that require manual entry.
    • Validates accuracy of reports prior to submission.
    • Submits reports timely according to health plan requirements.
    • Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reports
  • 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.


Jobs Rated Reports for Registered Nurse

Posted: 2020-10-20 Expires: 2020-11-28

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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Clinical Quality RN - WellMed - Telecommute Regionally near San Antonio, TX

UnitedHealth Group
San Antonio, TX 78205

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Registered Nurse
122nd2019 - Registered Nurse
Overall Rating: 122/199
Median Salary: $71,730

Work Environment
Very High
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