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 Utilization Management Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues, with Utilization Management (UM) organization determinations, both internal and external from vendors interfacing with health plans, and oversight of health plan delegated reports. Monitoring includes ongoing audits, improvement actions and overall feedback on the process to ensure adherence by Utilization Management (UM), and Inpatient Case Managers to requirements pertaining to NCQA and CMS. This position requires a current unrestricted nursing license (i.e. RN) in the applicable state, who is a subject matter expert and is able to provide innovative solutions to complex problems, oversees UM reporting functions, ensures accuracy through data validation and leads quality improvement initiatives for remediation.

Primary Responsibilities:

• Conducts audit reviews of Organization Determinations, Adverse Determinations and Notice of Medicare Non-Coverage documents (NOMNC) and Detailed Explanation of Non-Coverage (DENC) documents to assure accuracy and compliance with UM health plan, CMS, NCQA, URAC and Department of Insurance guidelines
• Utilizes audit tools to perform documentation audits on job functions within Utilization Management
  • 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 Medical Management Department(s) and the Utilization Departments
  • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
  • Identifies and communicates gaps between CMS 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 Utilization Management (RA UM) 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 UM Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, URAC, and Department of Insurance guidelines
  • Performs audit reviews including annual audits to evaluate policies, CMS compliance and adherence to RA UM health plans with regular audits focusing on compliance with Organization Determination and Adverse Determination regulations
  • Demonstrate understanding necessary to assess, review and apply criteria (e.g., MCG guidelines, CMS criteria, medical policy, and health plan specific criteria.)
  • Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness pharmacy audit reviews
  • 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
• Provides all required Regulatory Adherence Utilization Management (RA UM) reports to health plan
  • Validates accuracy of reports prior to submission
  • Submits reports timely according to health plan requirements
  • Analyze results, provide interpretation, and identify areas for improvement
  • Interfaces with IT and provides direction regarding additional reports or changes to RA UM reports
• Ensure Compliance with Relevant Processes, Procedures, and Regulations
  • Ensure compliance with accreditation requirements (e.g., NCQA, CMS) and relevant health plan requirements
  • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
  • 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
  • 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 near IH 10 W. The position is Hybrid and will require 3 days a week in-office.  

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
• Current unrestricted 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 at least two years of Utilization Management experience
• Knowledge and experience with CMS, URAC and NCQA
• Knowledge of Medicare and Medicaid benefit products including applicable state regulations
• Demonstrate knowledge of computer functionality navigation and proficiency with Microsoft Office applications required (e.g., Windows, Microsoft Office applications including Microsoft Word and Microsoft Excel)
• Demonstrate knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims databases)
• Willing to occasionally travel in and/or out-of-town as deemed necessary

Preferred Qualifications:

• Health Plan or MSO quality, audit or compliance experience
• Auditing, training or leadership experience
• Solid knowledge of Medicare and TDI regulatory standards
• Solid knowledge of process flow of UM including prior authorization and/or clinical appeals and grievance reviews

Physical & Mental Requirements:

• Ability to lift up to 25 pounds
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing Ability to use logical reasoning for simple and complex problem solving

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.