RN Regulatory Adherence UM Health Plan Auditor Texas
Company: Optum
Location: Fischer
Posted on: May 19, 2025
Job Description:
WellMed, part of the Optum family of businesses, is seeking a
Regulatory Adherence UM Health Plan Auditor to join our team in San
Antonio, TX. Optum is a clinician-led care organization that is
changing the way clinicians work and live.
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As a member of the Optum Care Delivery team, you'll be an integral
part of our vision to make healthcare better for everyone.
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At Optum, 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
collaborative environment that is guided by diversity and inclusion
while driving towards the Quadruple Aim. We believe you deserve an
exceptional career, and will empower you to live your best life at
work and at home. Experience the fulfillment of advancing the
health of your community with the excitement of contributing new
practice ideas and initiatives that could help improve care for
millions of patients across the country. Because together, we have
the power to make health care better for everyone. Join us and
discover how rewarding medicine can be while Caring. Connecting.
Growing together.
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The Regulatory Adherence Sr. Clinical Quality 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 oversight of health plan delegated reports. -Monitoring
includes review of the work of others that perform 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 interface 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 quality reports as well as health
plan reports on programs and metrics according to delegation
agreement. -This position requires a subject matter expert who is
able to provide innovative solutions to complex problems and lead
quality improvement initiatives for remediation.
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If you are located in Texas, you will have the flexibility to work
remotely* as you take on some tough challenges.
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Position Highlights & Primary 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
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- 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
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In 2011, WellMed partnered with Optum to provide care to patients
across Texas and Florida. WellMed is a network of doctors,
specialists and other medical professionals that specialize in
providing care for more than 1 million older adults with over
16,000 doctors' offices. At WellMed our focus is simple. We're
innovators in preventative health care, striving to change the face
of health care for seniors. WellMed has -more than 22,000+ primary
care physicians, hospitalists, specialists, and advanced practice
clinicians who excel in caring for 900,000+ older adults. Together,
we're making health care work better for everyone.
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You'll be rewarded and recognized for your performance in an
environment that will challenge you and give you clear direction on
what it takes to succeed in your role as well as provide
development for other roles you may be interested in.Required
Qualifications:
- 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
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Preferred Qualifications: -
- Health Plan or MSO quality, audit, or compliance
experience
- Previous auditing, training, or leadership experience
- Solid knowledge of Medicare and TDI regulatory standards
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Values Based Competencies:
- Integrity Value: Act Ethically
- Comply with Applicable Laws, Regulations and Policies
- Demonstrate Integrity
- Compassion Value: Focus on Customers
- Identify and Exceed Customer Expectations
- Improve the Customer Experience
- Relationships Value: Act as a Team Player
- Collaborate with Others
- Demonstrate Diversity Awareness
- Learn and Develop
- Relationships Value: Communicate Effectively
- Influence Others
- Listen Actively
- Speak and Write Clearly
- Innovation Value: Support Change and Innovation
- Contribute Innovative Ideas
- Work Effectively in a Changing Environment
- Performance Value: Make Fact-Based Decisions
- Apply Business Knowledge
- Use Sound Judgement
- Performance Value: Deliver Quality Results
- Drive for Results
- Manage Time Effectively
- Produce High-Quality Work
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*All employees working remotely will be required to adhere to
UnitedHealth Group's Telecommuter Policy
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The salary range for this role is $71,600 to $140,600 annually
based on full-time employment. Pay is based on several factors
including but not limited to local labor markets, education, work
experience, certifications, etc. UnitedHealth Group complies with
all minimum wage laws as applicable. In addition to your salary,
UnitedHealth Group offers benefits such as, a comprehensive
benefits package, incentive and recognition programs, equity stock
purchase and 401k contribution (all benefits are subject to
eligibility requirements). No matter where or when you begin a
career with UnitedHealth Group, you'll find a far-reaching choice
of benefits and incentives.
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OptumCare is an Equal Employment Opportunity employer under
applicable law and qualified applicants will receive consideration
for employment without regard to race, national origin, religion,
age, color, sex, sexual orientation, gender identity, disability,
or protected veteran status, or any other characteristic protected
by local, state, or federal laws, rules, or regulations.
-
OptumCare is a drug-free workplace. Candidates are required to pass
a drug test before beginning employment.
Keywords: Optum, Round Rock , RN Regulatory Adherence UM Health Plan Auditor Texas, Healthcare , Fischer, Texas
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