Senior Quality RN – Utilization Management
Senior Quality RN – Utilization Management
- CLINICAL – CLINICAL INTERVENTION & OPERATIONS
ABOUT THE ROLE
The Senior Quality Management Nurse, Utilization Management, will be responsible for the development and execution of a quality oversight program focused on Bright’s utilization management program. This position will ensure program policies and procedures meet relevant federal, state and accreditation statutes and standards. They will also coordinate regular monitoring and auditing of workflows. Lastly, the Quality Oversight Manager will be responsible for coordinating the federal and state requests for compliance reporting as well as audits.
- Development and execution of a quality oversight program for a utilization management program regular training, monitoring and audits including communicating status updates, results, and outcomes via written and oral report to internal and external stakeholders.
- Ensure utilization management program policies and procedures meet all federal and state guidelines as well as 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 UM activities.
- Coordinate and collaborate with the Compliance team in the preparation and execution of state and federal agency audits, including CMS audits. This may include leading mock audits, regular data universe audits and process audits.
- Identify areas and root causes of operational clinical issues that need corrective action and collaborate with the delivery team on the remediation activities.
- Ensure entry of data requirements into utilization management platform is consistent, accurate, and appropriate per workflow requirements and documentation standards.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s or Associates degree in Nursing highly preferred.
- Active RN license or similar clinical licensure in good standing with current state required.
- Three (3)+ years of utilization management/quality improvement experience required.
- Advanced knowledge and understanding of basic utilization management and quality improvement concepts required.
- Advanced knowledge of CMS, URAC and/or State utilization management statutes and standards required.
- Previous experience as a lead in a functional area or managing cross functional teams on large scale projects required.
- Previous experience developing, participating and/or leading audit program and/or process for oversight required.
- Experience translating complex regulations and standards into policies and procedures.
- Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative 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.
- Excellent writing skills, particularly in determination notification writing.
- 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.
- Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.
LICENSURES AND CERTIFICATIONS
- Active RN license or similar clinical licensure in good standing with current state
At Bright Health, we brought together the brightest minds from the health care industry and consumer technology and together we created Bright Health: a new, brighter approach to healthcare, built for individuals. Our plans are easy to manage, personalized and more affordable, giving people the quality care they deserve. Through our exclusive care partnerships with leading health systems in local communities we are reshaping how people and physicians achieve better health together.
We’re Making Healthcare Right. Together.
We’ve won some fun awards like: Great Places to Work, Modern Healthcare, Forbes, etc. But more than anything, we’re a group of people who are really dedicated to our mission in healthcare. Come join our growing team!
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
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