Registered Nurse Auditor - The Health Plan

 
Position: Registered Nurse Auditor - The Health Plan

Job ID: 160088

Location: US-TX-Houston

Department: Utilization Mgmt - Admin

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for an RN Auditor -- someone who works well in a fast-paced setting. In this position, you will complete associate quality audits of clinical staff, focused reviews, and problem identification. This role provides coaching and feedback to associates as necessary. The RN Auditor provides routine/scheduled and ad hoc audit reports including trend identification and root cause analysis, coordinates development of action plan for identified issues, and participates and assists in the development of necessary protocols, policies and procedures, and operational strategies for Clinical Services. This role also works with the management team to develop and provide individual and department-level performance improvement plans and activities as well as plan/process follow-ups.

 

Think you’ve got what it takes?



Responsibilities :

  • Performs monthly auditing of registered nurses and other clinical functions in Utilization Management, Case Management, Member Assessment Team, Health Management, and/or Disease Management
  • Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements
  • Assesses clinical staff regarding appropriate decision-making
  • Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to leadership
  • Assists in preparation for regulatory audits by performing file review and preparation
  • Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management
  • Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications
  • Assists training team with developing training materials or job aids as needed to address findings in audit results


Qualifications:

Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption

  • Associate’s degree in Nursing required
  • Bachelor’s degree in Nursing preferred
  • 2 years’ experience with Utilization Management, Case Management, Management Assessment Team, Health Management, Disease Management, and/or managed care experience required
  • 3 years’ experience in utilization management, disease management or case management in managed care, medical or behavioral health settings preferred
  • 2 years clinical auditing/review experience preferred


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