CMS and NCQA Utilization Management, RN - Florida Remote

Job description

Job Summary: We are seeking a highly skilled and experienced Registered Nurse (RN) to join our team as a Utilization Management Compliance Specialist. As a Specialist, you will apply your discipline-specific knowledge and skills in utilization management, compliance, and quality reporting to support the Company's operations and ensure adherence to Centers for Medicare and Medicaid Services (CMS) and National Quality Care Assessment (NQCA) guidelines. Essential Functions: - The essential functions listed represent the major duties of this role, additional duties may be assigned. - Serve as a liaison between internal clients and functional departments; help clients achieve their objectives by serving as a resource in the interpretation, application and compliance with internal and external laws, regulations, policies, procedures, standards and practices. - Identify risks, evaluate controls and prepare findings and recommendations. Implement compliance programs to prevent illegal, unethical or improper business practices. - Ensure through audits that the organization’s programs are consistently administered in compliance with organizational policies and procedures, contractual obligat...