Delegation Operations Nurse Auditor - LVN, Experienced

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.

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

Your Knowledge and Experience 

• 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 

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.