Sr Nurse - Quality & Acc.

HealthHelp's Senior Nurse - Quality and Accreditation is responsible for quality assurance activities that measure clinical review performance against client contract, regulatory, and accreditation requirements. The role identifies trends and root causes early so that issues are corrected before they result in client escalations or corrective action plans. The responsibilities include internal and external quality auditing, subject matter expertise with regard to regulatory standards, process improvement and cross-department collaboration and support. MAJOR RESPONSIBILITIES • Responsible for quality assurance review of clinical review departmental activities and compliance with applicable regulatory requirements, client contract requirements, and URAC and NCQA accreditation standards • Follows the standardized processes for conducting quality audits of review activity performed by staff participating in clinical review processes, including Interrater Reliability (IRR) audits, audits of adverse determination notices and supporting documentation, and physician reviewer audits completed with Medical Directors; recommends improvements to audit scope, sampling, and tools • Meets the department audit accuracy standard and participates in audit calibration • Provides quality scoring and trends to Clinical Review management for both individual and departmental levels, with root cause analysis of negative trends and recommended corrective actions; follows up with Clinical Review management to confirm that corrective actions for those findings were implemented • Recognizes and informs management of critical issues promptly, with the supporting facts and a recommended action • Contributes audit findings and case examples to the department's updates for Operations and Clinical Education • Facilitates the development and implementation of Quality Improvement Projects to address areas of opportunity for quality improvement • Maintains working knowledge of utilization management workflows, systems, and policies for each program audited; completes operational workflow training and keeps that knowledge current • Reports receipt date, notification date, and system timestamp discrepancies found during audits in accordance with the data integrity policy • Researches potential fraud, waste, and abuse ordering patterns identified during review and compiles cases for the manager • Prepares case files, evidence, and written responses for client delegation audits, accreditation surveys, and regulatory audits • Reviews operational policies and procedures against audit findings and requirement changes, and drafts recommended updates for the manager • Assists with compiling data for submission to the Quality Management Committee on a quarterly basis, ensuring that performance standards are measured and reported according to regulatory requirements • Serves as backup for the manager on assigned deliverables when designated, and shares audit methods with peers • Performs assigned non-auditing functions within Quality and Accreditation, including but not limited to: handling complaints; maintaining mandatory education/training logs for all new and existing employees and contractors; the credentialing of all clinical and any other licensed contractor or employee of HealthHelp; maintaining OIG and SAM logs on all clinical staff • Adheres to all current HIPAA, FWA, Consumer Health and Safety, and state and federal regulations pertaining to the clinical programs • Adheres to all regulatory requirements and complies with HealthHelp policies and procedures • Upholds professional standards and performs all work in a manner respectful of others • Delivers a high level of service and support to both internal and external clients • Promotes business focus which demonstrates an understanding of the company's vision, mission, and strategy • Performs other duties as assigned to meet business needs Qualifications: • Graduate of an accredited school of nursing, required • Active, unrestricted RN license in a state or territory of the U.S., required • Minimum of 3 years of utilization management experience at a health plan, utilization management vendor, or delegated utilization management organization, required • Minimum of 1 year of quality audit, quality assurance, or compliance audit experience, required • Working knowledge of CMS coverage requirements (NCD and LCD) and applicable state requirements; ability to learn and apply HealthHelp proprietary clinical guidelines; working knowledge of URAC and NCQA utilization management standards and of Medicare Advantage, Medicaid, and commercial decision and notification requirements • Demonstrated ability to identify trends in audit data, complete root cause analysis, and present findings clearly in writing • Demonstrated ability to work independently, meet deadlines, and apply feedback and training in practice • Proficient in Microsoft Office suite, including Excel to sort, filter, and summarize audit data • Three years of experience in acute care setting, preferred • Ability to speak English fluently • Excellent listening, oral, and written communication/presentation skills • Strong problem solving, interpersonal, and customer service skills in both face-to-face and remote settings • Strong critical thinking skills • Ability to work on multiple projects simultaneously and prioritize work to meet adapting deadlines • Ability to work in a collaborative fashion with team members in data collection, clinical review audits, and record maintenance • Ability to recognize potential and actual problems and work effectively within a team to develop appropriate solutions and implement effective action plans to address the problems ENVIRONMENT AND PHYSICAL DEMANDS • HIPAA-compliant remote location with reliable high-speed internet. • Ability to use the telephone, sit, enter data and view a PC screen for up to 8 hours. • Ability to prioritize in a multi-task environment. Compensation Disclosure The base salary for this position is $80,000 - $90,000 annually. This represents the base pay range that we reasonably expect to offer for this position. Final compensation will be determined based on a variety of factors, including but not limited to the candidate's experience, education, skillset, and location. • Geographic location • Overall professional experience • Directly relevant experience • Education and certifications • Industry knowledge and expertise • Skills and competencies In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range. WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois. Note: For complete compensation information, please refer to the job posting on our official careers page. Benefits Overview Our benefits package includes (but is not limited to): - Medical, dental, and vision insurance - Paid time off (PTO), holidays, and sick leave - 401(k) with company match or other retirement plan - Life and AD&D Insurance - Employee Assistance Program How to Apply Please submit your application, including a resume and optional cover letter, through our careers page or email to [redacted].