Senior Nurse – Quality & Accountability

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🤠 Texas – Remote

🤠 Texas – Remote

💵 $80k - $90k / year

⏰ Full Time

🟠 Senior

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WNS

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1996

⚖️ Legal

📦 Logistics

📣 Marketing

Legal • Logistics • Marketing

WNS is a global business process management company that operates across 13 countries with over 66 delivery centers and employs more than 62,000 people. The organization is committed to inclusivity and diversity, fostering a unique culture of co-creation and continuous learning. WNS offers various career opportunities across the Asia Pacific, Europe, Africa, and the Americas, and prides itself on its transparent and merit-based recruitment process. As a leader in its field, WNS focuses on nurturing future leaders and decision-makers while maintaining a strong emphasis on social responsibility through initiatives like the WNS Cares Foundation.

📋 Description

• Conduct quality assurance reviews of clinical review departmental activities for regulatory, client contract, URAC, and NCQA compliance • Conduct quality audits, including Interrater Reliability audits, adverse determination notice and documentation audits, and physician reviewer audits • Participate in audit calibration and meet department audit accuracy standards • Provide quality scoring, trend analysis, root cause analysis, and recommended corrective actions to Clinical Review management • Follow up with management to confirm corrective actions are implemented • Escalate critical issues with supporting facts and recommended actions • Contribute audit findings and case examples to Operations and Clinical Education updates • Facilitate Quality Improvement Projects • Maintain knowledge of utilization management workflows, systems, policies, and operational training • Report receipt date, notification date, and system timestamp discrepancies • Research potential fraud, waste, and abuse ordering patterns and compile cases • Prepare case files, evidence, and written responses for client delegation, accreditation, and regulatory audits • Review policies and procedures against audit findings and requirement changes; draft recommended updates • Compile quarterly data for the Quality Management Committee • Serve as backup for the manager on assigned deliverables and share audit methods with peers • Handle complaints, maintain education and training logs, credential licensed staff, and maintain OIG and SAM logs • Adhere to HIPAA, FWA, Consumer Health and Safety, and applicable state and federal regulations • Deliver service and support to internal and external clients • Perform other assigned duties to meet business needs

🎯 Requirements

• 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 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 • 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 collaboratively in data collection, clinical review audits, and record maintenance • Ability to recognize potential and actual problems and develop and implement appropriate solutions and action plans • 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

🏖️ Benefits

• 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 • Performance-based bonuses, incentive pay, or commissions may be available

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