Senior Clinical Quality RN — HEDIS & Compliance Leader

Optum; San Antonio (TX); On-site; USD 73,000 - 130,000; Full time

Job summary

WellMed, part of the Optum family, is seeking a seasoned RN to support quality and HEDIS initiatives in the Houston market. You will educate clinics, oversee audits, and lead discussions on performance results in collaboration with provider teams.

This role requires an active RN license, 5+ years of nursing, 2+ years managed care experience, CMS/NCQA/HEDIS knowledge, EMR navigation skills, and travel across the market with a valid driver's license.

Qualifications

• Active, unrestricted RN license.
• 5+ years of clinical nursing experience.
• 2+ years of managed care experience supporting Commercial, Medicare, Medicaid, or SNP populations.
• Experience with audits, delegation oversight, utilization management, quality improvement, or clinical compliance activities.
• Experience with quality reporting and audit documentation tools used within delegated oversight programs.
• Solid understanding of CMS, NCQA, HEDIS, and regulatory/accreditation requirements.
• Proficiency in Microsoft Outlook, Teams, Word, Excel, and PowerPoint; Proficiency in Copilot and AI-enabled tools.
• Proficiency in educating, influencing and presenting to providers and clinic leadership.
• Proven ability to navigate multiple EMR platforms used by provider groups.
• Reside in San Antonio, Austin, Waco, TX Market market.
• Willing and able to travel throughout the assigned market as needed.
• Valid driver's license required.

Responsibilities

• Support contracted providers within the Houston market on quality and HEDIS initiatives.
• Conduct provider and clinic education regarding quality measures and performance expectations.
• Perform delegated oversight activities, audits, monitoring, and compliance reviews.
• Analyze audit findings, identify trends and risks, and recommend corrective actions.
• Lead provider-facing meetings and communicate performance results.
• Support gap closure activities and quality improvement initiatives.

Skills

Microsoft Office Suite

AI tools (Copilot)

Provider education/presentation

EMR navigation

Education

Registered Nurse license

Advanced degree (preferred)

Tools

EMR systems

Job description

WellMed, part of the Optum family, is seeking a seasoned RN to support quality and HEDIS initiatives in the Houston market. You will educate clinics, oversee audits, and lead discussions on performance results in collaboration with provider teams.

This role requires an active RN license, 5+ years of nursing, 2+ years managed care experience, CMS/NCQA/HEDIS knowledge, EMR navigation skills, and travel across the market with a valid driver's license.