Universal American
Questions? Call Us!

If you have any questions, please call 1-866-249-8668, 8:00 a.m to 8:00 p.m in your local time zone (TTY users call 711) 7 days a week.

Shareholder or investor inquiries

Quality Assurance RN

Job Title
Quality Assurance RN
Job ID
1002479
Begin Date
5/12/16
Duration
Location
Houston,  TX
Other Location
Description
JOB DESCRIPTION
 
Does TexanPlus® sound familiar? If yes, that is because you recognize our Medicare Advantage health plan, TexanPlus HMO. Throughout Texas, TexanPlus is highly regarded by providers, case managers, and Medicare recipients alike. In fact, TexanPlus HMO has earned a 4-Star Quality Rating (out of 5) for 2014 and 2015, from the Centers for Medicare & Medicaid Services. That makes TexanPlus one of the highest rated Medicare plans in Beaumont and Houston! In order to meet the needs of our members we serve, we are looking for outstanding clinically skilled Registered Nurses and Licensed Vocational Nurses, who understand case management, disease management, utilization review and pre-certification to join our team. If you would like to be part of a winning team please read the job description below. The Medical Management (MM) Quality Assurance Specialist assists in the quality review and auditing processes within Medical Management. This includes Quality of Care reviews and monthly auditing for compliance standards of authorizations. As well, the position supports and assists with the development, review and approval of policies as they relate to functions within the MM service. Assists with attainment of operating and reporting goals.
 

Responsibilities:

  • Collaborates with QI team in the implementation of Quality Improvement activities.
  • Provides QOC reviews, documents according to standards, and presents cases as applicable for medical director review.
  • Audits the MM authorization monitoring system to ensure standards are met according to CMS guidelines.
  • Reviews authorizations to ensure supporting documentation from provider is accurate and meets guidelines and medical necessity.
  • Assist in the development and drafting of Medical Management Policies and Procedures.
  • Assist in performing department MM-QA audits to monitor consistency of documentation and implementation of processes throughout all markets.
  • Assist Medical Management Managers in preparation of internal and external audits.
  • Complies with guidelines and expectations as applicable to the Department and Health Plan.
  • Ensures that all medical records, authorizations and PHI are maintained securely.
  • Participates in departmental meetings and activities as required.
  • All other duties assigned by the manager and/or supervisor

Required Skills:

  • Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
  • Organizational skills with the ability to handle multiple tasks and/or projects at one time.
  • Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company.
  • Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization.
  • Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements.
  • Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
  • Problem solving skills with the ability to look for root causes and implementable, workable solutions.
  • Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision.
  • Able to function independently as well as an active team member depending on the situation and needs.
  • Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization

Required Experience:

  • Current nursing licensure, RN preferred.
  • College degree in Healthcare related field preferred.
  • Minimum 5 years in health related field.
  • Managed Care experience required/MA industry experience a plus.
  • Working knowledge of medical group/managed care environment
  • Knowledge of Medicare.
  • Strong presentation and interpersonal skills
  • Ability to work independently, as well as in a group/team setting
  • Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum
Universal American Corp. is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.
 
Required Skills

RN, Nursing, Inpatient, Outpatient, Skilled Nursing, Medicare, Medicaid, Quality Assurance
Openings
1

Option 1: Create a New Profile