Senior Nurse – Quality & Accountability

This is a fully remote position, open to applicants in Texas.

📋 Description

• Perform quality assurance evaluations of the clinical review department's activities to ensure compliance with regulatory, client contract, URAC, and NCQA standards.

• Execute quality audits, which include Interrater Reliability audits, audits of adverse determination notices and documentation, and evaluations of physician reviewers.

• Engage in audit calibration processes and achieve departmental audit accuracy benchmarks.

• Provide quality scoring, trend analysis, root cause analysis, along with suggested corrective measures to Clinical Review management.

• Follow up with management to verify the implementation of corrective actions.

• Raise critical issues, supported by facts and suggested actions.

• Contribute audit findings and case examples for updates in Operations and Clinical Education.

• Lead Quality Improvement Projects.

• Maintain familiarity with utilization management workflows, systems, policies, and operational training.

• Report discrepancies in receipt dates, notification dates, and system timestamps.

• Investigate potential fraud, waste, and abuse ordering patterns, compiling cases as needed.

• Prepare case files, evidence, and written responses for client delegation, accreditation, and regulatory audits.

• Review policies and procedures in relation to audit findings and changes in requirements; draft suggested updates.

• Compile quarterly data for the Quality Management Committee.

• Act as a backup for the manager on assigned deliverables and share auditing techniques with colleagues.

• Manage complaints, maintain education and training logs, credential licensed staff, and keep OIG and SAM logs current.

• Comply with HIPAA, FWA, Consumer Health and Safety, along with relevant state and federal regulations.

• Provide service and support to both internal and external clients.

• Execute other assigned tasks to fulfill business requirements.

⛳️ Requirements

• Graduate from an accredited nursing school, required.

• Possess an active, unrestricted RN license in a U.S. state or territory, required.

• Have a minimum of 3 years of experience in utilization management within a health plan, utilization management vendor, or delegated utilization management organization, required.

• Minimum of 1 year of experience in quality auditing, quality assurance, or compliance auditing, required.

• Familiarity with CMS coverage requirements (NCD and LCD) and state-specific requirements.

• Ability to learn and apply HealthHelp proprietary clinical guidelines.

• Knowledge of URAC and NCQA utilization management standards as well as Medicare Advantage, Medicaid, and commercial decision and notification requirements.

• Proven capacity to identify trends in audit data, conduct root cause analysis, and clearly present findings in written form.

• Demonstrated capability to work independently, meet deadlines, and incorporate feedback and training into practice.

• Proficient in Microsoft Office suite, particularly Excel, to sort, filter, and summarize audit data.

• Fluent in English, both spoken and written.

• Exceptional listening, oral, and written communication/presentation skills.

• Strong problem-solving, interpersonal, and customer service skills in both in-person and remote environments.

• Excellent critical thinking abilities.

• Capable of managing multiple projects concurrently and prioritizing tasks to meet shifting deadlines.

• Ability to collaborate effectively in data collection, clinical review audits, and record maintenance.

• Aptitude for identifying potential and actual problems, developing, and implementing suitable solutions and action plans.

• HIPAA-compliant remote work environment with reliable high-speed internet access.

• Ability to utilize the telephone, sit, enter data, and view a computer screen for extended periods of up to 8 hours.

• Competent in prioritizing tasks within a multi-tasking environment.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off (PTO), holidays, and sick leave.

• 401(k) plan with company matching or alternative retirement options.

• Life and AD&D Insurance.

• Employee Assistance Program.

• Opportunities for performance-based bonuses, incentive pay, or commissions may be available.