Delegation Oversight Nurse

Molina Healthcare•Long Beach, CA

18h•Remote

About The Position

This position is responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including delegation standards and requirements contained in the delegation agreement. The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. We are looking for LVN's with at least 3 years of UM experience, NCQA accreditation and knowledge of InterQual / MCG guidelines. Excellent computer multi-tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times. Experience with Appeals, Auditing, Prior Authorization, Compliance and Quality will be a good fit for this position. Further details to be discussed during our interview process. CA located – Remote position

Requirements

At least 3 years experience in health care, including 2 years experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience.
Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). License must be active and unrestricted in state of practice.
Knowledge of audit processes and applicable state and federal regulations.
Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines.
Ability to collaborate effectively with team members and internal departments.
Strong attention to detail with a focus on maintaining quality in all tasks.
Strong verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Nice To Haves

Registered Nurse (RN). License must be active and unrestricted in state of practice.
Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ).

Responsibilities

Coordinates, conducts, and documents pre-delegation and annual assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement as needed.
Works with Delegation Oversight Analyst on monitoring of performance reports from delegated entities.
Develops corrective action plans when deficiencies are identified, and documents follow up to completion.
Assists with meetings of the Delegation Oversight Committee.
Works with the Delegation Oversight Manager to develop and maintain delegation assessment tools, policies, and reporting templates.
Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees.
Participates as needed in Joint Operation Committees (JOC's) for delegated groups.
Assists in preparation of documents for CMS, State Medicaid, NCQA, and/or other regulatory audits as needed.