Senior Nurse, Quality & Accreditation — Remote QA Lead

HealthHelp, LLC; Houston (TX); Remote; USD 80,000 - 90,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

401(k) with company match

Paid time off

Life and AD&D Insurance

Employee Assistance Program

Job summary

HealthHelp, LLC is seeking a Senior Nurse to lead quality assurance and accreditation across clinical review activities, ensuring regulatory compliance and continuous improvement in utilization management workflows. The role involves cross-department collaboration and ongoing auditing.

Ideal candidates hold a US RN license with 3+ years in utilization management and QA experience, plus strong regulatory knowledge and Excel data skills. Remote-friendly role with a focus on HIPAA compliance.

Qualifications

• Graduate of an accredited school of nursing, required.
• Active, unrestricted RN license in the U.S., required.
• Minimum of 3 years of utilization management experience in health plan, UM vendor, or delegated UM organization, required.
• Minimum of 1 year of quality audit, QA, or compliance audit experience, required.
• Working knowledge of CMS coverage requirements (NCD/LCD) and URAC and NCQA standards.
• Demonstrated ability to identify trends in audit data and present findings clearly in writing.

Responsibilities

• QA review of clinical review activities and regulatory/compliance with URAC/NCQA requirements.
• Provide quality scoring and trends with root-cause analysis to management.
• Ensure audit accuracy and participate in calibration and updates of audit scope/tools.
• Prepare case files and written responses for accreditation/regulatory audits.
• Contribute to Quality Improvement Projects and ongoing staff training.

Skills

RN license

Utilization Management

Quality audits

Regulatory knowledge

Data analysis (Excel)

Education

BSN (Bachelor of Science in Nursing)

Tools

Microsoft Excel

Job description

HealthHelp, LLC is seeking a Senior Nurse to lead quality assurance and accreditation across clinical review activities, ensuring regulatory compliance and continuous improvement in utilization management workflows. The role involves cross-department collaboration and ongoing auditing.

Ideal candidates hold a US RN license with 3+ years in utilization management and QA experience, plus strong regulatory knowledge and Excel data skills. Remote-friendly role with a focus on HIPAA compliance.