Delegation Operations Nurse Auditor - LVN, Experienced

Blue Shield of California•Long Beach, CA

5d•Hybrid

About The Position

Your Role The Delegation Oversight Utilization Management team is responsible for the organization, tracking and data entry of IPA Utilization Management audits, issues, complaints and monitoring. Identifies root cause of the problem and maintains monthly reporting that track and compare patterns of delegated entities. The Delegation Operations Nurse Auditor-LVN-Experienced will report to the Manager of UMDO. In this role you will be assist in maintaining continuous quality improvement in the Utilization Management Delegation Oversight Clinical Audit ensuring that departmental and organizational goals are accomplished through oversight and facilitating Utilization Management compliance of the Plan Partners. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will: Be responsible for overseeing policy and procedure review and completing limited and less complex full desk or onsite Pre-delegation, Annual or follow-up audits /assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements. Act as the auditor in charge on small and less complex audits, with supervision, of Sr. management and other delegated non-clinical areas through to corrective action plan oversight. Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports. Educate the delegated entities and vendors on area of expertise including but not limited to claims payment management, credentialing management, financial solvency, and system controls. Collaborate on regulatory audits, findings responses or enforcements by regulatory agencies. Responsible for writing Corrective Action Plans and comprehensive summaries Knowledge of DMHC, DHCS, CMS, Title 22 CCR, Title 28, Title 42, and Medi-Cal, Medicare processing guidelines Ability to effectively communicate with internal and external associates Responsible for reviewing criteria on denial letters Responsible for handling multiple audits and able to prioritize workflow

Requirements

Current CA LVN License
Certificate/diploma in vocational nursing required or advanced degree preferred
Requires at least 3 years of prior relevant auditing experience in utilization management or prior out-patient authorization review preferred
Experience in auditing utilization management or prior out-patient authorization review preferred
Desired knowledge of accreditation entities and their requirements
Ability to work independently
Excellent verbal and written communication skills and interpersonal skills
Computer ease & literacy with Word, Excel, Power Point Skills

Nice To Haves

Desired knowledge of accreditation entities and their requirements

Responsibilities

Be responsible for overseeing policy and procedure review and completing limited and less complex full desk or onsite Pre-delegation, Annual or follow-up audits /assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements.
Act as the auditor in charge on small and less complex audits, with supervision, of Sr. management and other delegated non-clinical areas through to corrective action plan oversight.
Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
Educate the delegated entities and vendors on area of expertise including but not limited to claims payment management, credentialing management, financial solvency, and system controls.
Collaborate on regulatory audits, findings responses or enforcements by regulatory agencies.
Responsible for writing Corrective Action Plans and comprehensive summaries
Knowledge of DMHC, DHCS, CMS, Title 22 CCR, Title 28, Title 42, and Medi-Cal, Medicare processing guidelines
Ability to effectively communicate with internal and external associates
Responsible for reviewing criteria on denial letters
Responsible for handling multiple audits and able to prioritize workflow