Delegation Oversight Nurse (LVN, RN) - UM Audit (Field/Remote)
Company: Molina Healthcare
Location: Pico Rivera
Posted on: July 28, 2022
JOB DESCRIPTION Remote position with Travel to do on-site
audits. (M-F 8/8:30 AM to 5/5:30 PM PST) with flexibility for night
and weekends to meet audit deadlines
- Travel would be in Southern California Los Angeles, San
Bernardino, Riverside, San Diego, Imperial, Orange, Sacramento For
this position we are seeking a (RN or LVN) with previous experience
Utilization Management or NCQA accreditation 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. Further
details to be discussed during our interview process. Job Summary
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. KNOWLEDGE/SKILLS/ABILITIES
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. This includes, but is not limited to:
- 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
- Works with the Delegation Oversight Manager to develop and
maintain delegation assessment tools, policies, and reporting
- 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. JOB QUALIFICATIONS
Required Education Completion of an accredited Licensed Vocational
Nurse (LVN), or Licensed Practical Nurse (LPN) Program Required
- Minimum two years Utilization Review experience.
- Knowledge of audit processes and applicable state and federal
regulations. Required License, Certification, Association Active,
unrestricted State Licensed Vocational Nurse or Licensed Practical
Nurse in good standing. Preferred Education Completion of an
accredited Registered Nurse (RN) Program or a bachelor s degree in
Nursing. Preferred Experience
- Three-year NCQA, CMS, and/or state Medicaid UM auditing
- Three years experience in delegation oversight process and
working knowledge of state and federal regulations. Preferred
License, Certification, Association
- Active and unrestricted Certified Clinical Coder
- Certified Medical Audit Specialists (CMAS)
- Certified Case Manager (CCM)
- Certified Professional Healthcare Management (CPHM) Certified
Professional in Health Care Quality (CPHQ)
- or other healthcare
- or management certification To all current Molina employees: If
you are interested in applying for this position, please apply
through the intranet job listing. Molina Healthcare offers a
competitive benefits and compensation package. Molina Healthcare is
an Equal Opportunity Employer (EOE) M/F/D/V.
Keywords: Molina Healthcare, Pico Rivera , Delegation Oversight Nurse (LVN, RN) - UM Audit (Field/Remote), Accounting, Auditing , Pico Rivera, California
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