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

Function: Quality Assurance
Experience Level: Mid-Senior Level