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Registered Nurse, RN, Clinical Quality Specialist, UM, WellMed - San Antonio, TX

UnitedHealth Group

San Antonio, TX
Job Code:
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Job Details

733651 Registered Nurse RN Clinical Quality Specialist UM WellMed San Antonio TX

Registered Nurse, RN, Clinical Quality Specialist, UM, WellMed - San Antonio, TX (733651)

Position Description

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)  


**Please note: This is an office based position.
The office is located off of Northwest Parkway in San Antonio, TX**

The Quality Specialist is responsible for monitoring and reporting compliance issues with UM organization determinations both internal and external from vendors. Monitoring includes ongoing audits, improvement actions and overall feedback on the process to ensure that delegation requirements are met. This position also oversights UM delegate reporting functions and ensures reporting accuracy through a validation process.


Primary Responsibilities:

  • Conducts review of Organization Determinations, Adverse Determinations and Notice of Medicare Non-Coverage documents (NOMNC) 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) 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 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 delegation audits and assists business with supplying information as needed
  • Coordinates with UM Delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, URAC and Department of Insurance guidelines
  • Performs at least annual audits to evaluate policies, CMS compliance and adherence to UM plan with regular audits focusing on compliance with Organization Determination and Adverse Determination regulations
  • 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
  • Provides all required UM delegation reports to health plan
  • Validates accuracy of reports prior to submission
  • Submits reports timely according to health plan requirements
  • Interfaces with IT and provides direction regarding additional reports or changes to delegation reports
  • Performs all other related duties as assigned

Required Qualifications:

  • Bachelor of Science in Nursing, Healthcare Administration or a related field required. (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) or LPN/LVN 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+ or more years of experience in managed care with at least two years of Utilization Management experience
  • Knowledge and experience of CMS, URAC and/or NCQA
  • Proficiency with Microsoft Office applications
  • Must be willing to occasionally travel in and/or out-of-town as deemed necessary

Preferred Qualifications:

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

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

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 90,000+ 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)


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

Job Details

  • Contest Number733651
  • Job TitleRegistered Nurse, RN, Clinical Quality Specialist, UM, WellMed - San Antonio, TX
  • Job FamilyMedical and Clinical Operations
  • Business SegmentOptumCare

Job Location Information

  • San Antonio, TX
    United States
    North America
  • Other LocationsYoakum-Texas, TX
    Shiner-Texas, TX
    Helotes, TX
    Gonzales, TX

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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