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Registered Nurse, RN, Manager, Audit Management, WellMed - San Antonio, TX

UnitedHealth Group

San Antonio, TX
Job Code:
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Job Details

Registered Nurse, RN, Manager, Audit Management, WellMed - San Antonio, TX(Job Number:694733)

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)


Assesses, plans, implements and evaluates audit, quality and compliance programs for all Care Management programs and initiatives.  This role is responsible for maintaining departmental compliance with state and federal health plan requirements, Medicare guidelines and NCQA standards.  Facilitates implementation of new regulations in a timely manner; and assists in the development of policies and procedures, process metrics, data collection tools, and presentations of resultant data. This position is accountable for informing and educating the managerial staff and the nursing staff on clinical guidelines, management of departmental clinical workflow and operations. Additionally, this position will provide reports and analyses to senior management, will serve as a liaison with providers to ensure optimal customer service is provided by nursing staff, will serve as facilitator/leader for process improvement efforts and provide education for targeted areas.
Primary Responsibilities:
  • Assesses, plans, implements, and evaluates audit, quality and compliance programs for the department
  • Establishes thresholds and benchmarks based on NCQA data and monitors adherence to ensure criteria is met
  • Establishes documentation guidelines based on NCQA data and reviews/monitors adherence to ensure criteria is met
  • Manages and monitors processes related to achieving and maintaining audit requirements, NCQA compliance and/or accreditation
  • Oversees and coordinates preparation activities for health plan audits within the department
  • Prepares and serves as the departmental representative for the interview process with health plan surveyors and NCQA surveyors
  • Develops and maintains a Cultural Competency program structure for members, providers and staff to meet NCQA accreditation standards
  • Effectively plans, prepares, communicates, executes the audit process, and institutes corrective action/follow-up related to the audit process
  • Able to effectively receive audits in a professional, ethical, and objective manner interpreting departmental standards/requirements, with an awareness of potential legal and financial ramifications
  • Knowledge of principles of auditing and the auditing techniques of examining, questioning, evaluating, and reporting to determine a quality system’s adequacy and deficiencies
  • Selects and uses appropriate tools and methodologies to plan, implement, evaluate projects, and evaluate the effectiveness of the audit and quality system
  • Acquires and analyzes data using appropriate standard quantitative methods to facilitate process analysis and improvements and to identify trends and/or patterns of performance that indicate a need for further analysis
  • Utilizes knowledge, experience, and education to identify process/risk management improvement activities. Appropriately communicates this information to Director and participates, as necessary, on multidisciplinary process improvement teams/entities to address
  • Oversees and coordinates structured Quality Improvement Activities (QIA's) and/or quality projects, including tracking, analyzing, reporting and problem solving
  • Establishes performance improvement teams to address any issues identified and may participate in, lead, and facilitate these teams
  • Ensures all departmental operations and administrative processes are in place at all times to meet the needs of nursing staff and patients in clinic
  • Participates in the training of new staff to ensure quality and process consistency and assists in professional development training activities and education programs to keep staff abreast of health care trends and practices
  • Serves as a resource for the department regarding clinical guidelines, workflow processes, and computer applications for documenting interventions
  • Maintains current activities list in conjunction with the Project Management and Process Improvement Office
  • Analyzes and interprets performance measures as needed for quality improvement
  • Performs quality improvement studies as needed on nurse activities
  • Uses effective communication methods in various situations to support continuous improvement efforts
  • Implements Customer Satisfaction Surveys for audit requirements through various resources
  • Uses customer expectations and feedback to manage continuous improvement projects
  • Identifies and prioritizes product or service design and development on the basis of customer requirements and feedback
  • Performs or assists in the performance of special reviews or projects, upon request of the Director. May act as consultant/facilitator/resource to other areas/departments on identified risk/change control issues
  • Maintains consistency between all local, regional clinics in regard to process flow
  • Attends educational offerings to keep abreast of change and comply with licensing and regulatory requirements
  • Performs all other related duties as assigned
Please note: This is an office based position located off of Northwest Parkway in San Antonio, TX.

Job Clinical Quality Management
Primary Location US-TX-San Antonio
Organization WellMed Medical Mgmt, Inc
Schedule Full-time
Number of Openings 1
Apply on the Company Site

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