Delegation Oversight Nurse (LPN) - Utilization Management Experience Required

Job Description

Job Summary: Provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties:

• Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements.
• Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed.
• Works with delegation oversight analytics representatives on monitoring of performance reports from delegated entities.
• Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion.
• Assists with delegation oversight committee meetings.
• Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates.
• Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees.
• Participates as needed in joint operation committees (JOCs) for delegated groups.
• Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed.

Required Qualifications:

• 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.

Preferred Qualifications:

• 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).