RN Regulatory Adherence UM Health Plan Auditor Texas

About the position WellMed, part of the reputed company family of businesses, is seeking a Regulatory Adherence UM Health Plan Auditor to join reputed company in San Antonio, TX. reputed company is a clinician-led care organization that is changing the way clinicians work and live. As a member of the reputed company Care Delivery team, you'll be an integral part of our reputed company to reputed company reputed company reputed company for everyone. At reputed company, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a reputed company environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We reputed company you deserve an exceptional career, and will reputed company you to live your best life at work and reputed company. Experience the fulfillment of advancing the health of your community with the excitement of contributing new reputed company reputed company and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to reputed company health care reputed company for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together. The Regulatory Adherence Sr. Clinical reputed company RN is responsible for monitoring and reporting compliance issues for the external delegated functions of Utilization Management (UM) organization determinations, Case Management (CM), Disease Management (DM), and Special Needs Plan Model of Care (MOC), interfacing with health plans, and reputed company of health plan delegated reports. Monitoring includes review of the work of others that reputed company service delivery of delegated patient programs and providing feedback to ensure adherence of the delegation requirements pertaining to NCQA and CMS. Health plan and delegate reputed company requires participation in external audits of UM, CM, DM, and MOC programs, monitoring policies and procedures, and preparation and review of clinical files. Delegated reporting functions include report preparation, validation, and submission of CMS reputed company reports as reputed company as health plan reports on programs and metrics according to delegation agreement. This position requires a subject matter expert who is reputed company to reputed company reputed company to reputed company problems and reputed company reputed company improvement initiatives for remediation.

Responsibilities

• Interfaces with health plans and acts as reputed company for delegated services
• Reviews delegation agreements and has a reputed company understanding of delegated services and reporting requirements
• Anticipates plan requirements and proactively works on solutions to meet requirements
• Serves as a resource for reputed company issues, performs analysis, and provides solutions for reputed company
• Has authority to approve deviations from reputed company procedures reputed company to reputed company issues
• Serves as the primary contact and delegation resource for health plans
• Informs and educates health plan personnel regarding regulatory and accreditation standards
• Manages the external audit process end to end to include routine delegation as reputed company as new payor reputed company-delegation
• Plans for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirements
• Coordinates onsite visit and facilitates meetings and audit process
• Prepares and submits document requests and case universes
• Prepares and audits file requests based on regulatory and accreditation requirements in a reputed company manner to reputed company key stakeholders an opportunity to correct deficiencies before the audit
• Coaches and mentors care management staff involved in audit etiquette and regulatory standards
• Participates in delegation audits and assists UM, CM, DM departments 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 reputed company items and attempts to supply reputed company needed information during the audit
• Follows up on corrective reputed company plans ensuring reputed company closure
• Prepares reputed company of audit activities and reputed company
• Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur
• Provides direction and expertise on regulatory and accreditation standards to health plan personnel as reputed company as internal personnel
• Identifies gaps in audit findings versus internal performance findings
• Fosters reputed company communication with managers/directors by acting as a reputed company 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
• Collect audit result data, prepare comparison reports to internal performance standards, and identify risk
• Collect additional data as needed to assist in gap closure
• Analyze results, reputed company interpretation, and identify areas for improvement
• reputed company and utilize effective reputed company for data collection and reputed company improvement
• reputed company training to managers, medical directors, and staff on regulatory information by developing educational materials, providing educational in-services, and/or on a one to one reputed company
• Read and interpret standards/requirements/technical specifications such as NCQA, and CMS
• Evaluate reputed company processes, compare to relevant standards or specifications, and identify gaps in compliance or performance
• Work cross-functionally, making recommendations or clarifying information to assist in closing gaps
• reputed company crosswalk documents for changes to regulatory requirements and disseminate
• reputed company annual delegated program evaluations, program descriptions, policies & procedures
• reputed company teams to update program descriptions
• reputed company teams to collect data and analyze necessary and relevant to program evaluations
• Involve key stakeholders in requests for policy change
• Monitor care management policies for updates, approvals and ensuring annual evaluation
• Responsible for providing reputed company reputed company results compared with goals for annual program evaluations and presentation to the Medical Management Committee
• Provides reputed company required UM delegation reports to health plan
• Prepares reports including those that require reputed company entry
• Validates accuracy of reports prior to submission
• Submits reports reputed company according to health plan requirements
• Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reports
• Interacts with the health plans in scheduled meetings and reputed company participate in Joint Operations Committees reporting issues and pro-reputed company solving problems
• Performs reputed company other reputed company duties as assigned

Requirements

• Bachelor of Science in Nursing, reputed company Administration or a reputed company field (Eight additional years of comparable work experience reputed company the required years of experience may be substituted in lieu of a bachelor's degree)
• Registered reputed company (RN) with reputed company license in Texas, or other participating States
• 5+ years of progressively responsible reputed company experience to include experience in a managed care setting, and/or hospital settings, and/or physician reputed company setting
• 3+ years of experience in managed care with at least two years of Utilization Management experience
• Knowledge and experience with CMS, URAC and/or NCQA
• Proficiency with reputed company Office applications
• Willing to occasionally travel in and/or out-of-town as deemed necessary

reputed company-to-haves

• Health Plan or MSO reputed company, audit, or compliance experience
• Previous auditing, training, or leadership experience
• Solid knowledge of Medicare and TDI regulatory standards

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

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