Registered Nurse RN Utilization Management Quality Auditor San Antonio Texas

Optum • San Antonio, TX

412d

About The Position

The Registered Nurse RN Utilization Management Quality Auditor at Optum in San Antonio, Texas, is responsible for ensuring compliance with healthcare regulations and standards through auditing and monitoring of utilization management processes. This role involves conducting audits, reporting compliance issues, and leading quality improvement initiatives to enhance patient care and operational efficiency. The position requires a strong clinical background, analytical skills, and the ability to collaborate with various departments to drive improvements in healthcare delivery.

Requirements

• Bachelor of Science in Nursing or Associate Degree in Nursing with 2+ years of additional experience.
• Current unrestricted Registered Nurse (RN) license in Texas or other participating States.
• 5+ years of progressively responsible healthcare experience, including managed care and/or hospital settings.
• 3+ years of experience in managed care with at least 2+ years in Utilization Management.
• Knowledge and experience with CMS, URAC, and NCQA standards.
• Knowledge of Medicare and Medicaid benefit products and applicable state regulations.
• Proficiency with Microsoft Office applications (Word, Excel, etc.).
• Knowledge of specific software applications associated with the job function.

Nice To Haves

• Health Plan or MSO quality, audit, or compliance experience.
• Auditing, training, or leadership experience.
• Solid knowledge of Medicare and TDI regulatory standards.
• Solid knowledge of process flow of UM including prior authorization and/or clinical appeals.

Responsibilities

• Conducts audit reviews of Organization Determinations, Adverse Determinations, and Notice of Medicare Non-Coverage documents to assure accuracy and compliance.
• Utilizes audit tools to perform documentation audits on job functions within Utilization Management.
• Performs regular audits to ensure data entry accuracy and 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 revisions in daily operations.
• Reports on departmental functions including data entry accuracy and monthly trends of internal audits.
• Prepares monthly and/or quarterly summary reports compiling data for all markets.
• Participates in the development, planning, and execution of auditing processes.
• Fosters open communication with managers/directors by acting as a liaison between departments.
• Identifies and communicates gaps between CMS requirements and internal documentation audits to appropriate departments.
• Manages and performs tasks related to annual audit reviews for contracted Health Plans.
• Prepares and audits files for submission as required.
• Participates in Regulatory Adherence Utilization Management audits and assists business with supplying information as needed.
• Guides and influences the audit process by ensuring adherence to the scope of the audit.
• Follows up on action items and corrective action plans ensuring timely closure.
• Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur.
• Provides direction and expertise on regulatory and accreditation standards to internal personnel.
• Coordinates with RA UM Delegated partners to ensure adherence to all regulations and guidelines.

Benefits

• Health insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree
• Number of Employees: 10,001+ employees