Reports to: VP Quality, Chief Compliance/Privacy Officer

Salary Range: DOE and Non-Exempt

Position Description:

The Senior Quality Management and Audit Nurse will be responsible for the development and execution of a quality oversight program focused on tango's compliance, utilization review and management program. This position will ensure program policies and procedures meet relevant federal, state, delegated health plan compliance, UM and accreditation statutes and standards. They will also coordinate regular monitoring and auditing of workflows, member file review (including assessing for over/under utilization patters) and adherence to NCQA and health plan standards.

Primary duties include, but are not limited to:

Essential Functions:

• Processes and assists in monitoring and oversight through audits and education for health plan member’s prior and re-authorization requests as outlined by company and health plan (as applicable) policy.
• Development and execution of a quality oversight program for the tango utilization management program that encompasses 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 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) 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.
• Facilitates communication and provides ongoing customer service support to payer plan case managers, patients and provider staff and team members.
• Periodic after-hours availability to address after hour health plan member needs related to home health management.
• Reviews documentation and provides feedback to clinicians regarding CMS Chapter 7 and Milliman Care Guidelines to ensure accurate assessment and review data, medical records reflect compliance with medical necessity, homebound status, visit utilization supported by individual patient assessment/documentation support and transition (discharge) planning.
• Identifies problems related to the quality of patient care and refers them to the Quality Assurance Committee/QPUC.
• Assists the Compliance and Utilization Review Committee/QPUC in the assessment and resolution of utilization review problems.
• Other activities as assigned.

Office Location:

Phoenix, Arizona with remote capabilities dependent on business needs.

Qualifications:

• An active, unrestricted Licensed Practical Nurse (LPN) or Registered Nurse (RN), 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 program of practical/vocational nursing.
• Has at least five years of general nursing experience in home health, medical, surgical, or critical care, and at least three years of utilization review/management, or case management and experience in home health.
• Is detail oriented and displays good organizational skills as well as good 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 and federal requirements.
• 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 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.
• 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.

Knowledge and Experience:

• Requires knowledge in the areas of home health community-based services; utilization/case management experience. Must have a working knowledge of homecare, managed care, medical/nursing staff procedures, and community resources. NCQA and URAC knowledge is required.
• Computer skills such as MS Office products - Outlook, Excel, Word, Adobe and the ability to work within multiple electronic medical management systems.
• 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, NCQA, URAC and/or State utilization management statutes and standards required.

Continuing Education Requirements:

Company personnel are expected to participate in appropriate continuing education as may be requested 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.