RN, Delegation Oversight Auditor

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP's focuses on 5 Core Values in the workplace:

* Integrity

* Accountability

* Collaboration

* Trust

* Respect

Disclaimers:

* Flexible work schedule is based on job duties, department, organization, or business need.

* Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

Under the general direction of the Compliance Director, the RN, Delegation Oversight Auditor leads, coordinates, and participates in delegation oversight audits of Gold Coast Health Plan's vendors, service providers and delegated subcontracted providers according to regulatory and contractual requirements. In support of the Compliance Director, the RN, Delegation Oversight Auditor assists in the liaison role between the subcontracted providers in the delegation oversight process. The position will also lead the delegation clinical oversight audit process, develop reports regarding audits, and analyze, track and trend audit findings. A second core function of the position is to support the Gold Coast Health Plan's compliance department. The focus in this area is to convey information to and problem-solve issues for internal and external stakeholders. Provide guidance on regulatory requirements and reporting. Assist with regulatory audit(s) preparation and coordination.

Amount of Travel Required: 30 - 40%

Work Schedule: Occasional travel to multiple sites and different locations.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

Class Characteristics:

The incumbent performs a variety of administrative duties that require a degree of analytical, organizational, and technical skills and exercises a level of discretion and judgment appropriate for the scope of the position. While the supervision of others is minimal at this time, this is a management level position.

Major Duties and Responsibilities:

* Responsible for continuous quality improvements within the Delegation Oversight program.

* Leads coordination and performance of pre-delegation and annual audits for delegates related clinical program oversight.

* Responsible for Clinical Compliance Program delegation oversight audits which includes, pre-audit letters, audit reporting requirements, audit tools,

* Responsible for coordination for scheduling audits, development of audit findings, including aggregating and analysis of audit results, and writing audit reports including any corrective action plans required of delegates.

* Maintain accurate recordkeeping of all delegation oversight audits and ensure all deadlines are met.

* Oversee and assists in the revision of delegation oversight audit tools in accordance with standards set by ICE, NCQA, the Plan's policies and procedures and other State and Federal guidance tools as required.

* Provides training, education, and consultation as necessary to delegates.

* Collaborates with Delegation Oversight staff and Health Services Department on identify topics and developing agenda for Joint Operations Meeting (JOM) with delegates.

* Attends and presents at Compliance Committee, Quality Improvement Committee, and others, as appropriate. Directs and creates memos and applicable charts and graphs for committee presentation.

* Stays informed about the latest developments in delegation oversight field, through relevant subject matter resources, professional associations, industry conferences, training seminars, and other information resources.

* Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including delegation standards and requirements contained in the delegation agreement

* Assists in the development of and is responsible for the implementation of departmental objectives to support organization strategies. Maintains effective communication with various levels of the organization and with external organizations

* Other duties as assigned

POSITION QUALIFICATIONS

Competency Statements

* Analytical Skills - Ability to use thinking and reasoning to solve a problem.

* Technical Aptitude - Ability to comprehend complex technical topics and specialized information.

* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

* Judgment - The ability to formulate a sound decision using the available information.

* Interpersonal - Ability to get along well with a variety of personalities and individuals.

* Relationship Building - Ability to effectively build relationships with customers and co-workers.

* Presentation Skills - Ability to effectively present information publicly.

SKILLS & ABILITIES

Requirements:

Education:

* High School Graduate or General Education Degree (GED): Required

* Bachelor's Degree (four-year college or technical school) Required, Field of Study: BSN, Business, Health Sciences, Managed Care

Experience:

* 5+ years of experience in a clinical setting performing Utilization Review, Delegation Oversight Auditing UM activities

* 5 + years NCQA, CMS, and/or state Medicaid UM auditing experience

* 3 + years of experience in supporting, training, and mentoring others in Managed Care clinical functions such as prior authorization, medical record reviews, member grievances, or quality reviews

Computer Skills: Demonstrate advanced proficiency in Microsoft Word, Excel, Access, and PowerPoint.

Licenses:

* Active, current, and unrestricted California License as a Registered Nurse (RN)

* Ability to establish, nurture and maintain strong and effective working relationships with the GCHP and Delegated Entity staff

* Ability to maintain detailed and accurate records, follow oral and written directions, prepare written agendas, and transcribe minutes

* Ability to think and work effectively under pressure

* Ability to deal with public contact; decision making, concentration.

Preferred:

Experience:

* Project Management experience is preferred

Certifications:

* Certified Medical Audit Specialists (CMAS)

* Certified Professional Healthcare Management (CPHM)

* Certified Professional in Health Care Quality (CPHQ)

* Certified Professional in Utilization Review (CPUR)

* Certified Case Manager (CCM)