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The Regulatory Adherence Utilization Management Sr. Clinical Quality RN is responsible for monitoring and reporting compliance issues, with Utilization Management (UM) organization determinations, both internal and external from vendors interfacing with health plans, and oversight of health plan delegated reports. Monitoring includes ongoing audits, improvement actions and overall feedback on the process to ensure adherence by Utilization Management (UM), and Inpatient Case Managers to requirements pertaining to NCQA and CMS. This position requires a current unrestricted nursing license (i.e. RN) in the applicable state, who is a subject matter expert and is able to provide innovative solutions to complex problems, oversees UM reporting functions, ensures accuracy through data validation and leads quality improvement initiatives for remediation.

Primary Responsibilities:

• Conducts audit reviews ofOrganization Determinations, Adverse Determinations and NoticeofMedicareNon-Coveragedocuments(NOMNC)andDetailedExplanationof Non-Coverage (DENC) documents to assure accuracyand compliance withUM health plan, CMS, NCQA, URAC and Department of Insurance guidelines

• Utilizesaudittoolstoperformdocumentationaudits onjob functionswithinUtilization Management

• Performsregularauditstoensuredataentry accuracy

• PerformsregularauditstoensureCompliance ofrequireddocumentation

• Communicatesregularauditresultstomanagementandinterfaceswithmanagers,staffand training tomakerecommendations onpotentialtraining needs or revision indaily operations

• Reports ondepartmentalfunctions toinclude,dataentryaccuracyandmonthlytrendsof internal audits

• Preparesmonthlyand/ orquarterlysummaryreportcompilingdata forallmarkets

• Preparesmonthlyand/orquarterlydetailed andtrendingemployeereport

• Participatesinthedevelopment, planning,andexecutionofauditing processes

• Fosters open communication with managers/directors by acting as a liaison betweentheTrainingDepartment(s),theMedicalManagementDepartment(s)and the Utilization Departments

• Identifiesandcommunicateswithappropriatedepartments,teams,andkey leadership on internal audit results and/or deficiencies

• Identifies and communicates gaps between CMS requirements and internal documentationauditsto appropriatedepartments,teams,andkeyleadership

• Managesandperformstasksrelatedto annualauditreview(ormorefrequent reviewas requested) for contracted Health Plans as well as pre-delegation review with potential Health Plans

• Preparesandauditsfilesforsubmissionasrequired

• ParticipatesinRegulatoryAdherenceUtilizationManagement (RAUM)audits and assists business with supplying information as needed

• Guidesand influencestheaudit processbyensuringthat auditorsadheretothe scope of the audit

• Followsuponactionitemsandattemptstosupplyallneeded informationas needed

• Followsuponcorrectiveactionplansand improvement actionplanensuring timely closure

• Monitorsdatacollectiontoolsandensuresupdatesoccur asregulatoryand accreditation changes occur

• Providesdirectionandexpertiseonregulatoryandaccreditationstandardsto internal personnel

• Coordinates with RA UM Delegated partners to ensure adherence to all regulations, contractualagreements,CMS,NCQA,URAC,andDepartmentofInsuranceguidelines

• Performsauditreviews includingannualauditstoevaluatepolicies,CMScompliance and adherence to RA UM health plans with regular audits focusing on compliance with Organization Determination and Adverse Determination regulations

• Demonstrateunderstanding necessarytoassess,reviewandapplycriteria(e.g.,MCG guidelines, CMS criteria, medical policy, and health plan specific criteria.)

• Applyknowledgeofpharmacologicalandclinicaltreatment protocolto determine appropriateness pharmacy audit reviews

• Preparesasummaryreportofeachevaluationincludinganydeficiencies and corrective action plans

• Providesregularfollow-upwithdelegates forcompletionofcorrectiveactionplans and improvement action plans

• Identifiesandcommunicateswithappropriatedepartments,teams,andkey leadership on internal audit results and/or deficiencies

• ProvidesallrequiredRegulatoryAdherenceUtilizationManagement(RAUM)reportsto health plan

• Validatesaccuracyofreportspriortosubmission

• Submitsreportstimelyaccording tohealthplanrequirements

• Analyzeresults,provideinterpretation,andidentifyareasfor improvement

• InterfaceswithITandprovidesdirectionregardingadditionalreportsorchangesto RA UM reports

• EnsureCompliancewithRelevantProcesses,Procedures,andRegulations

• Ensurecompliancewithaccreditationrequirements(e.g.,NCQA,CMS)and relevant health plan requirements

• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to makeclinicaldecisions, improveclinicaloutcomesandachievebusinessresults

• Follow internalpolicies/procedures(e.g.,jobaids,medicalpolicyand benefit documents)

• IdentifiesandcommunicategapsbetweenCMSandNCQArequirementsand internal documentation audits to appropriate departments, teams, and key leadership

• Recognizewhenadditionalregulations mayapply, research, andcollect additional data as needed to obtain relevant information

• Analyzeresults,provideinterpretation,andidentifyareasfor improvement

• Providing internalandexternalresultscomparedwithgoalsfor annual program evaluations and presentation to the Medical Management and Utilization Management, and Clinical Education Departments

• Performsallotherrelateddutiesas assigned

This is an office-based position near IH 10 W. The position is Hybrid and will require 3 days a week in-office.

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 (associate degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor's degree)

• Current unrestrictedRegisteredNurse(RN)withcurrent license inTexas,orother participating states

• 5+ years ofprogressively responsible healthcare experience to include experience ina managedcaresetting,and/orhospitalsettings,and/orphysicianpracticesetting

• 3+yearsofexperience inmanagedcarewithat least twoyearsofUtilization Management experience

• KnowledgeandexperiencewithCMS, URACandNCQA

• KnowledgeofMedicareandMedicaidbenefit productsincludingapplicablestateregulations

• DemonstrateknowledgeofcomputerfunctionalitynavigationandproficiencywithMicrosoft Office applications required (e.g., Windows, Microsoft Office applications including Microsoft Word and Microsoft Excel)

• Demonstrateknowledgeofspecificsoftwareapplicationsassociatedwiththe jobfunction (e.g., navigationofrelevant computer applicationsorsystems, intranet databases, records management or claims databases)

• Willingtooccasionallytravelinand/orout-of-townasdeemednecessary

Preferred Qualifications:

• HealthPlanorMSOquality,auditor complianceexperience

• Auditing,trainingorleadershipexperience

• SolidknowledgeofMedicareandTDIregulatorystandards

• Solidknowledgeofprocess flowofUM includingpriorauthorizationand/orclinical appeals and grievance reviews

Physical & Mental Requirements :

• Ability to lift up to25pounds

• Ability to sit for extended periods of time

• Abilitytostandforextendedperiodsoftime

• Abilitytousefine motorskillstooperateofficeequipment and/ormachinery

• Abilitytoreceiveandcomprehendinstructionsverballyand/orinwriting Abilityto use logicalreasoning for simple and complexproblemsolving

Values Based Competencies Employee

• IntegrityValue: ActEthically

• ComplywithApplicableLaws,RegulationsandPolicies

• DemonstrateIntegrity

• CompassionValue:FocusonCustomers

• IdentifyandExceedCustomerExpectations

• ImprovetheCustomerExperience

• RelationshipsValue:ActasaTeamPlayer

• CollaboratewithOthers

• DemonstrateDiversityAwareness

• LearnandDevelop

• RelationshipsValue:CommunicateEffectively

• InfluenceOthers

• ListenActively

• SpeakandWriteClearly

• InnovationValue:Support ChangeandInnovation

• ContributeInnovativeIdeas

• WorkEffectivelyinaChangingEnvironment

• PerformanceValue:MakeFact-BasedDecisions

• ApplyBusinessKnowledge

• UseSoundJudgement

• PerformanceValue:DeliverQualityResults

• DriveforResults

• ManageTimeEffectively

• ProduceHigh-QualityWork

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.