Delegation Operations Nurse Auditor - RN, Senior (Oncology)
Blue Shield of CaliforniaYour Role
The Delegation Oversight team is responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS, DHCS, LA Care and DMHC requirements including delegation standards and requirements contained in the delegation agreement. The Delegation Operations Nurse Auditor- RN - Senior will report to the Manager of UMDO. In this role you will assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit ensuring that departmental and organizational goals are accomplished through oversight and facilitating Utilization Management compliance of the Plan Partners.
Responsibilities
Your Work
In this role, you will:
Be responsible for overseeing policy and procedure review and completing full/complex 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 large and complex audits – providing direction and guidance to support auditors of provider claims, provider dispute mechanism, credentialing and other delegated non-clinical areas through to corrective action plan oversight with minimal supervision required.
Perform special audits of providers as requested by regulators, contracting, and internal management with oversight by Lead Auditor.
May manage projects requiring the responsibility of delegating work and reviewing resulting work product.
May be responsible for providing guidance, coaching and training to other employees within job area
Develop and implement Corrective Action Plan (CAP) for medical groups that are out of compliance with delegated responsibilities, with timely follow up actions of CAP. Interpret statistics and plan for actions taken to improve utilization management
Work with management to design and implement tools and materials that are compliant with regulatory, legislative and Blue Shield mandated requirements
Design work plans and workflows to facilitate the audit, quality and cost of healthcare initiatives
Responsible to assist in preparation of documents for NCQA, CMS, DHCS, LA Care and DMHC requirements, and/or other regulatory audits as needed
Participate in industry collaborative teams
Qualifications
Your Knowledge and Experience
Current CA RN license required
Bachelors of Science in Nursing or advanced degree preferred
Requires 5 years of prior relevant experience
Requires 2 years of oncology experience
Experience in auditing of claims, credentialing and/or re-credentialing preferred.
Requires strong analytical and problem-solving skills
Strong working knowledge of regulatory standards and regulations preferred
Ability to solve complex issues and identify solutions preferred
Desired knowledge of accreditation entities and their requirements
Ability to work independently
Excellent verbal and written communication skill and interpersonal skills
Computer ease & literacy with Word, Excel, Power Point Skills preferred