DELEGATION OVERSIGHT NURSE- Full Time

UHS•Riverside, CA

About The Position

SUMMARY: The Delegation Oversight Nurse performs activities to assure compliance with Health Plan requirements. The Nurse will manage activities to meet health plan requirements in areas such as – routine reporting, ad hoc reporting, annual oversight audit preparation, annual audit oversight completion, response to CAPs, and follow-up with medical groups to assure CAP implementation and compliance. Performs activities to promptly, efficiently, and accurately complete all health plan, state, federal, and other regulatory compliance processes with minimal to moderate supervision. Develop strong and positive working relationships with Health Plan representatives, clinical operations, and Medical Staff Services. Has a strong command of regulatory and accrediting requirements and health plan requirements. The Delegation Oversight Nurse works closely with business leaders in the development and implementation of external vendor initiatives aligned with the plan’s business, compliance, and performance improvement strategies. The role will support the Compliance Program to ensure compliance with Federal and State laws and regulations (Centers for Medicare and Medicaid Services, Department of Managed Health Care, Department of Health Care Services, CA Department of Insurance), contract provisions, accreditation standards, and internal policies and procedures.

Requirements

Associate degree required, Bachelor's preferred.
Minimum 3 years’ experience in Medical Management (Utilization Management, Appeals and Grievances, and/or Concurrent Review).
Over 2 years of experience in a health plan or healthcare auditing, compliance and/or operations.
Awareness and experience with HIPAA requirements for healthcare communications preferred.
Familiarity with developing and implementing auditing and monitoring processes across systems, internal areas, and first-tier downstream-related entities (FDRs).
Knowledge of Compliance Program principles to include analyzing risk assessments, performing audits, contracting, creating reports, educating and following up with the business area to ensure processes exist to demonstrate compliance with Federal and State requirements.
Current and unrestricted Licensed Practical Nursing or Licensed Vocational Nurse certificate from an accredited Nursing Program in California.
Registered Nurse (RN) preferred/desired.

Nice To Haves

Registered Nurse (RN) preferred/desired.

Responsibilities

Oversight of delegated and compliance operations with health plans.
Timely follow-up and completion of necessary follow-up action that may include, educational letters, training, corrective action plan (CAP), concurrent review, and any additional audits.
Coordination and scheduling of various audits.
Serve as a regulatory resource person and trainer to staff regarding regulatory requirements, health plan standards, and processes.
Maintain efficient and accurate records.
Actively participate in both internal & external meetings and webinar training sessions.
Tracking & collection of incoming required UM documents.
Ensure timeliness of required Health Plan reports.
Identify patterns, deficiencies, and trend audit findings.
Review denial letters for clinical criteria and appropriate language.
Coordinates and gathers documentation to respond to audits conducted either internally or externally.
Prepare delegate compliance reports and tracking logs.
Assist with the policy and procedures updates, as necessary.
Support the Delegation Oversight Analyst in the development and validation of reports regarding audits, including analyzing, tracking, and monitoring compliance with regulatory and health plan requirements.
Other duties as assigned, as needed.