Senior Nurse: Quality & Accreditation Leader

WNS Global Services; Houston (TX); On-site; USD 80,000 - 90,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

PTO, holidays and sick leave

401(k) with company match

Life and AD&D Insurance

Employee Assistance Program

Job summary

WNS Global Services in Houston seeks a Senior Nurse - Quality and Accreditation to lead quality assurance activities, ensuring compliance with client contracts, regulatory standards, and accreditation requirements. The role analyzes trends, identifies root causes, and implements corrective actions to prevent escalations.

Responsibilities include internal/external audits, documentation, and collaboration across departments to drive continuous quality improvement and adherence to HIPAA and

Qualifications

• RN license required and active
• Minimum 3 years of utilization management experience in health plan/vendor/organization
• Minimum 1 year of quality audit/compliance audit experience
• Working knowledge of CMS coverage requirements (NCD/LCD) and state requirements
• Knowledge of URAC and NCQA utilization management standards and Medicare Advantage/Medicaid/commercial requirements
• Ability to identify trends in audit data and perform root cause analysis
• Ability to work independently and meet deadlines
• Proficient in Microsoft Office (Excel)

Responsibilities

• Quality assurance review of clinical review activities for regulatory and contract requirements
• Conduct quality audits including IRR audits and review of adverse determinations
• Maintain audit accuracy and participate in calibration
• Provide quality scoring and trend analysis to management with root-cause actions
• Report discrepancies with supporting facts and recommended actions
• Contribute audit findings to Operations and Clinical Education updates
• Develop and implement Quality Improvement Projects
• Maintain knowledge of utilization management workflows and policies
• Report data discrepancies per data integrity policy
• Research potential fraud, waste, and abuse patterns
• Prepare case files for audits and regulatory reviews
• Update policies based on audit findings
• Assist with data for Quality Management Committee
• Serve as backup to manager on deliverables
• Handle complaints and maintain training logs
• Credentialing of clinical staff and contractors
• Maintain HIPAA and other regulatory compliance
• Deliver high-level service to internal and external clients
• Promote alignment with company strategy
• Perform other duties as assigned

Skills

English fluency

Microsoft Excel

CMS knowledge

Analytical thinking

Communication skills

Time management

Independent worker

Problem solving

Education

RN license (Active, unrestricted)

Tools

Microsoft Office

Job description

WNS Global Services in Houston seeks a Senior Nurse - Quality and Accreditation to lead quality assurance activities, ensuring compliance with client contracts, regulatory standards, and accreditation requirements. The role analyzes trends, identifies root causes, and implements corrective actions to prevent escalations.

Responsibilities include internal/external audits, documentation, and collaboration across departments to drive continuous quality improvement and adherence to HIPAA and