Senior Nurse - Quality and Accreditation (Fully Remote)

HealthHelp; United States; Remote; USD 80,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

PTO & Holidays

401(k) match

Life insurance

Job summary

HealthHelp is seeking a RN-licensed professional to perform internal and external quality audits of clinical review activities, including interrater reliability and adverse determination notices.

You will provide quality scoring and trend analysis to management, with root cause analysis and recommended corrective actions, while maintaining knowledge of utilization management workflows and policies across programs.

Qualifications

• Graduate of an accredited school of nursing with an active, unrestricted RN license in the U.S.
• Minimum of 3 years of utilization management experience at a health plan, UM vendor, or delegated UM organization.
• At least 1 year of quality audit, quality assurance, or compliance audit experience.

Responsibilities

• Perform internal and external quality audits of clinical review activities.
• Provide quality scoring and trend analysis to management with root cause analysis and recommended corrective actions.
• Maintain working knowledge of utilization management workflows, systems, and policies for each program audited.

Skills

Quality audits

Utilization management

Interrater reliability

Education

Nursing degree (RN)

Job description

• Perform internal and external quality audits of clinical review activities, including interrater reliability and adverse determination notices.
• Provide quality scoring and trend analysis to management with root cause analysis and recommended corrective actions.
• Maintain working knowledge of utilization management workflows, systems, and policies for each program audited.

Qualifications:

• Graduate of an accredited school of nursing with an active, unrestricted RN license in a U.S. state or territory.
• Minimum of 3 years of utilization management experience at a health plan, UM vendor, or delegated UM organization.
• At least 1 year of quality audit, quality assurance, or compliance audit experience.
• Base salary range of $80,000 - $90,000 annually, with potential for performance-based bonuses.
• Comprehensive benefits package including medical, dental, vision insurance, PTO, holidays, sick leave, 401(k) match, life insurance, and employee assistance program.
• Equal opportunity employer committed to diversity and inclusion.

HealthHelp

WNS is an AI-powered leader in intelligent operations and transformation serving over 700 clients across industries like banking, healthcare, and insurance. With 66,000+ employees across 13 countries, the company focuses on human-led solutions and sustainable outcomes.