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

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