Sr Clinical Quality RN Regulatory Adherence Utilization Management WellMed – San Antonio, TX

UnitedHealth Group
April 1, 2021
San Antonio, TX
Job Type


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 Regulatory Adherence Utilization Management (RA UM) Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues with Utilization Management (UM) Organization Determinations Appeals and Grievances for oversight of health plan delegated reports, and internal and external audits from vendors interfacing with health plans.  Monitoring includes ongoing audits, improvement actions and overall feedback on the process to ensure that Medical Management, (MM), UM and Inpatient Case Managers audit requirements pertaining to NCQA and CMS are met.  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. 
There is an option to Telecommute/work from home temporarily with the expectations that the position will be an office based position in the future. The office is located off of Network Blvd in San Antonio, TX, 78249. 
Primary Responsibilities:
  • Conducts audit reviews of Organization Determinations Appeals and Grievances (ODAG), Adverse Determinations, Notice of Medicare Non-Coverage documents (NOMNC) and Detailed Explanation of Non-Coverage (DENC) documents to assure accuracy and compliance with UM 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 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 and 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
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
  • Knowledge of computer functionality navigation and proficiency with Microsoft Office applications required (e.g., Windows, Microsoft Office applications including Microsoft Word and Microsoft Excel)
  • 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)
  • Must be willing to occasionally travel in and/or out-of-town as deemed necessary
  • You will be asked to perform this role in an office setting or other company location
  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained

Preferred Qualifications:

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

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

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.

Job Keywords: WellMed, Healthcare, Bilingual, Registered Nurse, RN, Clinical Quality Specialist, Utilization Management, UM, NOMNC/CMS/URAC/NCQA regulations, managed care, transition planning/complex care case management, San Antonio, New Braunfels, 78249, Texas, TX

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