Quality and Audit Nurse (LPN or RN) (Remote)

Brief Description tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care. We are currently looking for a Quality and Audit Nurse to join our growing team! Position Description The Quality and Audit Nurse (LPN/RN) will be responsible for ensuring the appropriateness, effectiveness, and compliance of home healthcare services. The role involves reviewing member records, conducting audits, and analyzing data to identify areas for identifying any over/under utilization patterns, and identifying improvement in auditing, compliance, and utilization management processes and adherence to NCQA UM. The goal is to optimize resource use, ensure member safety, and comply with NCQA, health plan and all Federal/State regulatory requirements. Office Location:

• Office located at 2415 E. Camelback Rd., Suite 700, Phoenix, AZ 85016
• (Remote)

Responsibilities

And Duties Responsibilities include, but are not limited to the following:

• Conduct auditing of utilization reviews to assess the appropriateness, medical necessity, and efficiency of home healthcare services provided to members. Processes and assists in monitoring and oversight through audits and education for health plan member’s prior, post and re-authorization requests as outlined by company , regulatory and health policy.
• Analyze utilization data and identify trends, patterns, and opportunities for improvement in healthcare service delivery.
• Collaborate with internal team members, healthcare providers, insurance companies, and other stakeholders to gather necessary information and ensure compliance with regulatory guidelines.
• Enforce and create quality improvement initiatives to enhance the efficiency and effectiveness of home healthcare services.Review and interpret healthcare policies, regulations, and guidelines to ensure compliance and adherence to industry standards.
• Maintain accurate and detailed documentation of auditing utilization review activities, findings, and recommendations.
• Provide feedback and education as applicable to clinicians regarding best practices and strategies for complying with regulatory and health plan rules.
• Stay updated with changes in healthcare regulations and industry standards, ensuring that all utilization review activities are in compliance.
• 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 health plan and CMS audits. This may include preparation of files, leading mock audits, regular data universe audits and process audits.
• Identify areas and root causes of operational issues that need corrective action and collaborate with the business team(s) on the remediation activities.
• Ensure entry of data requirements into utilization management software 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, members and provider staff and team members.
• Periodic after-hours and weekend rotation and availability to address after hour health plan grievance and appeals process related to home health services and management of care.
• Reviews documentation and provides feedback to clinicians regarding CMS Chapter 7, 16 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/QPUCS.
• Assists the Compliance and Utilization Review Committee/QPUC in the assessment and resolution of utilization review issues.
• Other activities as assigned.

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