Compliance and Quality Nurse Auditor

POSITION: Compliance and Quality Nurse Auditor

REPORTS TO: Chief Compliance and Privacy Officer

POSITIONDESCRIPTION:

The Compliance and Quality Nurse Auditor will be responsible for ensuring the appropriateness, effectiveness, and compliance of home healthcare services. The role involves reviewing member records, conducting audits, and analyzing data to identify areas for identifying any over/under utilization patterns, and identifying improvement in auditing, compliance, and utilization management processes and adherence to NCQA UM. The goal is to optimize resource use, ensure member safety, and comply with NCQA, health plan and all Federal/State regulatory requirements.

Primarydutiesinclude,butarenotlimitedto:

ESSENTIALFUNCTIONS:

• Conduct auditing of utilization reviews to assess the appropriateness, medical necessity, and efficiency of home healthcare services provided to members. Processes and assists in monitoring and oversight through audits and education for health plan member’s prior, post and re-authorization requests as outlined by company , regulatory and health policy.
• Analyze utilization data and identify trends, patterns, and opportunities for improvement in healthcare service delivery.
• Collaborate with internal team members, healthcare providers, insurance companies, and other stakeholders to gather necessary information and ensure compliance with regulatory guidelines.
• Enforce and create quality improvement initiatives to enhance the efficiency and effectiveness of home healthcare services.
• Review and interpret healthcare policies, regulations, and guidelines to ensure compliance and adherence to industry standards.
• Maintain accurate and detailed documentation of auditing utilization review activities, findings, and recommendations.
• Provide feedback and education as applicable to clinicians regarding best practices and strategies for complying with regulatory and health plan rules.
• Stay updated with changes in healthcare regulations and industry standards, ensuring that all utilization review activities are in compliance.
• Ensure utilization management program policies and procedures meet all federal and state guidelines as well as NCQA/URAC accreditation standards as well as be the department resource to ensure understanding of timeliness measures and other regulatory and accreditation UM standards.
• Coordinate the development of reporting required by state and federal agencies and consulting with the configuration team regarding opportunities to enhance the efficiency and quality for users of the information system to support Compliance and UM activities.
• Coordinate,participate (as required)andcollaboratewith the Compliance teamin the preparation and execution of state and federal agency audits, including health plan and CMS audits. This may include preparation of files, leading mock audits, regular data universe audits and process audits.
• Identifyareasandrootcausesofoperationalissuesthatneedcorrectiveactionandcollaborate with the business team(s) on the remediation activities.
• Ensure entry of data requirements into utilization management software platform is consistent, accurate, and appropriate per workflow requirements and documentation standards.
• Facilitates communication and provides ongoing customer service support to payer plan case managers, members and provider staff and team members.
• Periodic after-hours and weekend rotation and availability to address after hour health plan grievance and appeals process related to home health services and management of care.
• Reviews documentation and provides feedback to clinicians regarding CMS Chapter 7, 16 and Milliman Care Guidelines to ensure accurate assessment and review data, medical records reflect compliance withmedicalnecessity,homeboundstatus,visitutilizationsupportedbyindividualpatientassessment/ documentation support and transition (discharge) planning.
• IdentifiesproblemsrelatedtothequalityofpatientcareandrefersthemtotheQualityAssurance Committee/QPUCS.
• AssiststheComplianceandUtilizationReviewCommittee/QPUCintheassessmentandresolutionof utilization review issues.
• Otheractivitiesasassigned.

OFFICELOCATION:

• Office located 7600 North 16th Street, Suite 140 Phoenix, AZ 85020
• REMOTE

QUALIFICATIONS

• An active, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN), license to practice as a health professional in a state (including Arizona) or territory of the United States is required for this role. Is a graduate of an accredited school/program of registered nursing or practical/vocational nursing.
• Has at least five years of general nursing experience in home health, medical/surgical, geriatrics, or critical care, and at least three years of utilization review/management, or case management with experience in home health.
• Is detail oriented and displays organizational skills as well as professional oral and written communication skills.
• Is self-directed, flexible, cooperative, and exhibits the ability to work with minimal supervision.
• Working knowledge of home care regulatory, Federal and State requirements such as Medicare, Medicaid, and Commercial guidelines.
• Experience translating complex regulations and standards into policies and procedures, job aides and teaching materials as applicable.
• Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative team based environment.
• Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities
• Experience with problem management, change control and how to influence change without direct control within a decentralized business unit culture.
• Ability to develop strong cross-functional and collaborative relationship with internal and external partners, including the ability to work with a wide variety of people and personalities.
• Excellent organizational and time management skills, with the ability to prioritize and manage multiple tasks and deadlines.
• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint) and other relevant software applications.
• Periodic after-hours and weekend rotation and availability to address after hour health plan grievance/appeals process related to home health services and management of care.

KNOWLEDGEAND EXPERIENCE:

Requires knowledge in the areas of home health community-based services; utilization/case managementexperience.Musthaveaworkingknowledgeofhomecare,managedcare,medical/nursing staff procedures, and community resources. NCQA and URAC knowledge is required.

ComputerskillssuchasMSOfficeproducts-Outlook,Excel,Word,Adobeandtheabilitytoworkwithin multiple electronic medical management systems.

Three(3) years ofutilizationmanagement/quality improvementexperience required.

Advancedknowledgeandunderstandingofbasicutilizationmanagementandqualityimprovement concepts required.

AdvancedknowledgeofCMS,NCQA,URACand/orStateutilizationmanagementstatutesand standards required.

CONTINUINGEDUCATION REQUIREMENTS:

Company personnelareexpectedtoparticipateinappropriatecontinuingeducationas may berequested and/or required by their immediate supervisor. In addition, company personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All company personnel must attend mandatory educational programs.

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.