Become a part of our caring community and help us put health first
 

The Senior Compliance Nurse reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Senior Compliance Nurse work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Compliance Nurse ensures mandatory reporting completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

The Senior Compliance Nurse Responsibilities:

• Internal Audits and Monitoring: Conduct NCQA audits per assignment (including stretch assignments/ad hoc audits) to assess compliance with:

• Reporting and Documentation: Random selection and analysis of cases to assess outcome and metrics of market compliance with NCQA must pass UM elements.

• Audit Calibration: Verify findings to maintain data quality and validation for statistical reliability prior to revealing audit results to markets. 

• NCQA Fail-factor elements: Effectively ascertain the complicated and layered nuances of primary contributors to perceived examiner risks during a NCQA survey.

• Root Cause Analysis: Identify the key contributors of NCQA fail factors for tracking/trending purposes to mitigate issues prior to/during lookback periods and surveys. 

• Criteria and Policy: Collaborate with markets to ensure consistent application and understanding of criterion and policies are applied.

• Market Collaboration: Proactive planning and partnership to adequately support markets and communicate pertinent audit findings.

• Stakeholder Engagement: Large forum meeting facilitation to present, illustrate and discuss detailed and complex NCQA audit findings.

“Pre-Game” Meetings with Lead Medical Directors, Centralized Leadership, Compliance and all NCQA Auditors for collective consensus and consistency in audit approaches in preparation for market meetings.

Market Meetings with Market Leaders, Lead AMDs, Regional AMDs, Template Team, Accreditation Partners, Compliance, Centralized Letters Team, etc.), a collaborative forum to discuss audit findings with a “live” and rebuttal process; present a high-level overview of significant findings & trends; provide market support and education.

• Advisory Role: Serve as key advisors to market management on compliance-related matters related to audit findings.

• Cultivate Trust: Foster a united culture with key market stake holders to gain agreement on audit findings and reduce risks related to recognized issues.

• New Market Rollouts: Develop and refine NCQA audit tactics related to new Medicaid market implementation to ensure consistency in compliance and quality.

• Risk Management: Identify potential compliance risks and work with business partners to develop strategies to mitigate them.

• Adopt Best Practices: Proactive identification, risk reduction, and continuous monitoring to navigate and limit potential NCQA survey uncertainties.

• Benchmark Data: Monitoring audit measures’ effectiveness by leveraging and trending NCQA fail factor opportunities for improvements or adaptations in methodologies.

• Enhanced Decision-Making: Discuss and debate audit strategies’ efficacy and revisit audit approaches to secure team reliability and credibility.

• Training and Education: Partner with leadership to develop and deliver NCQA audit centered training to markets and business partners.

• Foster Awareness:  Communicate and provide understanding of pertinent issues, compliance requirements, and interpretation of NCQA standards.

• Shadow Sessions: Offer opportunities to observe audit procedures and fundamental contributors to NCQA fail factor elements. 

• Template Teams: Provide guidance and feedback in conjunction with business partners and Lead Medical Directors to ensure denial language is consistent across markets.

Use your skills to make an impact
 

Required Qualifications:

• Registered Nurse with a Bachelor's degree in Nursing, BSN, and an ac