Senior Nurse – Quality & Accountability

WNS

. Conduct quality assurance reviews of clinical review departmental activities for regulatory, client contract, URAC, and NCQA compliance .

Posted 11/5/2026full-timeRemote • Texas • United StatesSenior💰 $80,000 - $90,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in quality assurance and compliance auditing within clinical review environments, with a strong focus on regulatory standards and utilization management workflows. Proficient in conducting audits, performing root cause analysis, and implementing corrective actions to enhance operational efficiency.

Highest-signal resume keywords

Active RN LicenseUtilization Management ExperienceQuality Audit ExperienceKnowledge of CMS Coverage RequirementsProficient in Microsoft Office Suite

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Quality AssuranceQuality AuditingRoot Cause AnalysisTrend AnalysisClinical ReviewData CompilationRegulatory ComplianceDocumentation AuditsInterrater Reliability AuditsCorrective Action Implementation

Soft Skills

Strong Problem SolvingExcellent Communication SkillsInterpersonal SkillsCritical ThinkingAbility to Work Independently

Certifications & Qualifications

RN License

Industry Keywords

URAC StandardsNCQA StandardsMedicare AdvantageMedicaidHealthPlan ComplianceFraud DetectionConsumer Health and SafetyHIPAA ComplianceOperational TrainingQuality Management Committee

About the role

Key responsibilities & impact

Conduct quality assurance reviews of clinical review departmental activities for regulatory, client contract, URAC, and NCQA compliance
Conduct quality audits, including Interrater Reliability audits, adverse determination notice and documentation audits, and physician reviewer audits
Participate in audit calibration and meet department audit accuracy standards
Provide quality scoring, trend analysis, root cause analysis, and recommended corrective actions to Clinical Review management
Follow up with management to confirm corrective actions are implemented
Escalate critical issues with supporting facts and recommended actions
Contribute audit findings and case examples to Operations and Clinical Education updates
Facilitate Quality Improvement Projects
Maintain knowledge of utilization management workflows, systems, policies, and operational training
Report receipt date, notification date, and system timestamp discrepancies
Research potential fraud, waste, and abuse ordering patterns and compile cases
Prepare case files, evidence, and written responses for client delegation, accreditation, and regulatory audits
Review policies and procedures against audit findings and requirement changes; draft recommended updates
Compile quarterly data for the Quality Management Committee
Serve as backup for the manager on assigned deliverables and share audit methods with peers
Handle complaints, maintain education and training logs, credential licensed staff, and maintain OIG and SAM logs
Adhere to HIPAA, FWA, Consumer Health and Safety, and applicable state and federal regulations
Deliver service and support to internal and external clients
Perform other assigned duties to meet business needs

Requirements

What you’ll need

Graduate of an accredited school of nursing, required
Active, unrestricted RN license in a state or territory of the U.S., required
Minimum of 3 years of utilization management experience at a health plan, utilization management vendor, or delegated utilization management organization, required
Minimum of 1 year of quality audit, quality assurance, or compliance audit experience, required
Working knowledge of CMS coverage requirements (NCD and LCD) and applicable state requirements
Ability to learn and apply HealthHelp proprietary clinical guidelines
Working knowledge of URAC and NCQA utilization management standards and Medicare Advantage, Medicaid, and commercial decision and notification requirements
Demonstrated ability to identify trends in audit data, complete root cause analysis, and present findings clearly in writing
Demonstrated ability to work independently, meet deadlines, and apply feedback and training in practice
Proficient in Microsoft Office suite, including Excel to sort, filter, and summarize audit data
Ability to speak English fluently
Excellent listening, oral, and written communication/presentation skills
Strong problem solving, interpersonal, and customer service skills in both face-to-face and remote settings
Strong critical thinking skills
Ability to work on multiple projects simultaneously and prioritize work to meet adapting deadlines
Ability to work collaboratively in data collection, clinical review audits, and record maintenance
Ability to recognize potential and actual problems and develop and implement appropriate solutions and action plans
HIPAA-compliant remote location with reliable high-speed internet
Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours
Ability to prioritize in a multi-task environment

Benefits

Comp & perks

Medical, dental, and vision insurance
Paid time off (PTO), holidays, and sick leave
401(k) with company match or other retirement plan
Life and AD&D Insurance
Employee Assistance Program
Performance-based bonuses, incentive pay, or commissions may be available