RN Regulatory Adherence UM Health Plan Auditor Texas

About the position Responsibilities • Interfaces with health plans and acts as liaison for delegated services • Reviews delegation agreements and has a clear understanding of delegated services and reporting requirements • Anticipates plan requirements and proactively works on solutions to meet requirements • Serves as a resource for complex issues, performs analysis, and provides solutions for resolution • Has authority to approve deviations from standard procedures related to complex 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 well as new payor pre-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 timely manner to provide 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 action items and attempts to supply all needed information during the audit • Follows up on corrective action plans ensuring timely closure • Prepares summary of audit activities and outcomes • 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 well as internal personnel • Identifies gaps in audit findings versus internal performance findings • Fosters open communication with managers/directors by acting as a liaison 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, provide interpretation, and identify areas for improvement • Develop and utilize effective methods for data collection and quality improvement • Provide 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 basis • Read and interpret standards/requirements/technical specifications such as NCQA, and CMS • Evaluate current 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 • Develop crosswalk documents for changes to regulatory requirements and disseminate • Oversee annual delegated program evaluations, program descriptions, policies & procedures • Lead teams to update program descriptions • Lead 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 all internal and external results compared with goals for annual program evaluations and presentation to the Medical Management Committee • Provides all required UM delegation reports to health plan • Prepares reports including those that require manual entry • Validates accuracy of reports prior to submission • Submits reports timely 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 actively participate in Joint Operations Committees reporting issues and pro-actively solving problems • Performs all other related duties as assigned Requirements • Bachelor of Science in Nursing, Healthcare Administration or a related field (Eight 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 at least two years of Utilization 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 • 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 Apply tot his job Apply To this Job