VP Quality Improvement Regulatory Adherence Texas

    • San Antonio, TX

Position Description

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life's best work.(sm)

WellMed provides concierge - level medical care and service for seniors, delivered by physicians and clinic stat that understands and care about the patient's health. WellMed's proactive approach focuses on prevention and the complete coordination of care for patients. WellMed is now part of the Optum division under the greater UnitedHealth Group umbrella.

The primary responsibility of the VP, Quality Improvement Regulatory Adherence (UM, CM, DM, SNP) is to direct, plan, implement, and evaluate compliance activities related to Medical Management delegated functions. The VP facilitates implementation of new regulations in a timely manner and ensures that departmental maintain continuous compliance with health plan, state and federal requirements (i.e. CMS, URAC, NCQA standards and the Department of Insurance guidelines). This position oversees internal performance monitoring processes and coordinates delegation activities with the internal operational UM teams.

Primary Responsibilities:

  • Directs activities to ensure that department adheres to all regulations, contractual agreements, and applicable CMS, SNP, NCQA, URAC and other accreditation standards as well as internal policies related to regulatory or oversight agencies.
    • Coordinates and activates preparation activities for MSO and health plan audits for UM, CM, DM and SNP MOC functions (i.e. CMS/NCQA SNP uploads, CMS Data Validation).
    • Identifies and communicates with appropriate teams on regulatory notifications, audit results and/or deficiencies.
  • Oversees, coordinates and ensures delegated partners adhere to all regulations, contractual agreements, and CMS, SNP, NCQA, URAC and other applicable accreditation standards.
    • Coordinates and activates preparation activities for contracted delegated entities where we perform designated UM, CM, DM and/or SNP MOC functions.
    • Oversees auditing and monitoring activities with delegated partners annually and as required.
    • Communicates with delegation teams on regulatory notifications, audit results and/or deficiencies.
  • Oversees monthly, quarterly and annual reporting activities with delegated partners, health plan and regulatory agencies to comply with continuous tracking and monitoring requirements.
  • Plans, directs, communicates, and executes internal quality assurance and performance auditing processes to assess UM, CM, DM and SNP MOC compliance with documentation requirements and as needed for improvement strategies in preparation for regulatory visits.
    • Oversees the development of appropriate audit tools to use.
    • Ensures systematic methodologies are utilized for audit processes.
    • Develops and directs feedback processes for employees and managers on internal audit results.
    • Develops and directs reporting processes to track and trend internal results.
  • Evaluates effectiveness of auditing processes by assessing result trends over time, and recommends strategies for ongoing improvement efforts.
  • Provides guidance for development of training modules in conjunction with the business units and training teams, and as needed, delivers training to staff on regulatory topics impacting compliance activities.
  • Monitors compliance and compiles materials needed to file with applicable Department of Insurance (TDI) or other UR agency for licensure / certification in states where required.
  • Provides consistent application of policies and practices, feedback and direction for staff and team to ensure cohesive department growth and individual development.
  • Performs all other related duties as assigned.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:
  • Master's degree in Nursing, Healthcare Administration, Business Administration, or other related field (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a master's degree)
  • Active Registered Nurse (RN) license in the applicable state
  • 8+ more years of related experience in direct operational accountability for UM, CM, DM and SNP MOC programs or oversight for compliance of these programs
  • Demonstrated proficiency in project management and process improvement methodologies
  • Proven ability to integrate large-scale systemic change processes with a ride range of stakeholders and department managers
  • Knowledge of current trends compliance and auditing processes
  • Able to establish cooperative and collaborative working relationships in the course of performing assigned duties
  • Must have a basic understanding of standards and requirements such as URAC, NCQA, and CMS (i.e., Medicare) for UM, CM, DM and SNP MOC programs
  • Proficiency with Microsoft Office applications to include Power Point, Visio, Word and Excel
  • Ability to effectively report data, facts and recommendations in oral and/or written form
  • Willing to travel in and/or out-of-town as deemed necessary
  • Health Plan or MSO quality, audit or compliance experience

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi - specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and 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.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: WellMed, Healthcare, Bilingual, Quality Program Management & Ops Support , HEDIS, Policy and Procedures, Medical Practice, analytical, Vice President, San Antonio, New Braunfels, Seguin, Gonzales, Shiner, Yoakum, Boerne, Texas, TX

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