Delegation Oversight Clinical Auditor RN II

L.A. Care Health Plan•Los Angeles, CA

4d•$88,854 - $142,166

About The Position

The Delegation Oversight Clinical Auditor RN II ensures that delegates performing Utilization Management (UM) functions for L.A. Care comply with regulatory requirements, new legislation, contractual obligations, and L.A. Care standards. The position maintains and updates policies, procedures, workflows, processes, and audit tools, and works collaboratively with Regulatory Affairs & Compliance. It supports continuous quality improvement and helps ensure that Plan Partners, Participating Provider Groups (PPGs), Specialty Health Plans, vendors, and contracted provider networks meet applicable requirements. The role performs annual, focused, periodic, and follow-up audits; identifies deficiencies and repeat issues; reviews mitigation responses and corrective action plans; monitors performance; and prepares clear, complete audit documentation and reports. It develops methods to track and trend compliance, identifies system-wide issues and opportunities for improvement, and helps prepare the Delegation Oversight Department and audit team for internal and external reviews. The auditor communicates and serves as a liaison with Plan Partners and PPGs on UM issues, provides training, education, consultation, and coaching, and offers best-practice guidance and continuous feedback to improve access, utilization performance, and compliance. The position presents summary results to L.A. Care's UM Committee, conducts interrater reliability testing, collaborates across departments to improve processes, maintains HIPAA confidentiality, and assists with special projects and other duties as assigned.

Requirements

At least 7 years of experience in a clinical setting, including at least 3 years in a managed care setting in Utilization Management or Case Management.
Associate's degree in Nursing.
Active, current, unrestricted California Registered Nurse (RN) license.
Knowledge of issues pertaining to Medi-Cal and other HMO and IPA contracts and payers.
Ability to manage and organize large volumes of data.
Knowledge of accreditation entities and their requirements.
Excellent verbal and written communication skills and interpersonal skills.
Good working knowledge of regulatory requirements and standards.
Ability to work independently.
Ability to solve complex issues and identify creative solutions.
Computer literacy and proficiency with Word, Excel, and PowerPoint.

Nice To Haves

Bachelor's degree in Nursing.

Responsibilities

Ensure delegate compliance with UM policies, procedures, letter templates, workflows, processes, audit tools, regulatory requirements, and new legislation.
Collaborate with Regulatory Affairs & Compliance and stay informed about changes affecting UM requirements.
Prepare the Delegation Oversight Clinical Audit team for internal audits and audits of Plan Partners and PPGs; develop mechanisms to track and trend compliance progress and identify areas for improvement.
Prepare the Delegation Oversight Department for external regulatory reviews and ensure staff work and review documents are prepared to meet regulatory requirements.
Complete annual, focused, and periodic audits, including identifying deficiencies, reviewing mitigation responses and corrective action plans, identifying repeat deficiencies, and maintaining accurate audit documentation.
Conduct periodic monitoring of delegate performance in critical deficiency areas, complete follow-up audits and reports, and recommend options for addressing ongoing or significant deficiencies.
Update audit tools to meet regulatory, contractual, and L.A. Care requirements.
Develop and conduct ongoing monitoring, including file reviews, letters, and supplemental reports, and present summary results to L.A. Care's UM Committee.
Communicate routinely with assigned Plan Partners and PPGs, track and trend their compliance with UM standards, and identify system-wide issues.
Provide training, education, consultation, coaching, and best-practice guidance to Plan Partners and PPGs.
Collaborate with Clinical Auditors to identify topics and develop agendas for JOMs and Plan Partner visits or communications.
Develop and implement procedures to ensure compliance with care coordination and documentation of linked and carved-out services.
Conduct Interrater Reliability Testing for referral management and oversight for new staff and physicians, and annually or as needed for existing staff and physicians.
Work with other departments to create or improve interdepartmental processes that meet regulatory requirements.
Maintain confidentiality in accordance with HIPAA requirements.
Assist coworkers with special projects or workload as needed, identify opportunities to improve job functions, and communicate barriers to supervisors.
For the Performance Monitoring focus, monitor delegates' continuous compliance and corrective action plans, attend designated committees and meetings, monitor supplemental UM reports, and report to management.
For the Behavioral Health focus, design and maintain behavioral health-specific audit tools, policy requirements, and monitoring programs; coordinate with Specialty Health Plans, Plan Partners, internal Behavioral Health units, and the Medical Director of Behavioral Health; and attend designated committees and meetings.
Perform other duties as assigned.