Delegation Oversight Nurse Remote based in CA (Must have a CA License)

ClickJobs.io; Council Bluffs (IA); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare provider is seeking a Delegation Oversight Nurse to ensure compliance with regulatory requirements. This role involves overseeing delegated activities, conducting assessments, and supporting audits. Ideal candidates will have experience in Utilization Review and hold an active LVN or LPN license in California.

Benefits

Competitive Benefits

Qualifications

• At least two years of Utilization Review experience.
• Active LVN or LPN license in California.

Responsibilities

• Oversee compliance with NCQA, CMS, and State Medicaid requirements.
• Develop corrective action plans for deficiencies.

Skills

Utilization Review

Audit Processes

Education

LVN or LPN Program

RN Program

Tools

Healthcare Quality

Clinical Coding

Job description

Delegation Oversight Nurse Remote based in CA (Must have a CA License)

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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.

Job Description

The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates comply with all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. This role also supports the Delegation Oversight Manager with various team duties, including:

• Coordinating, conducting, and documenting pre-delegation and annual assessments to ensure compliance with relevant requirements.
• Distributing audit results, follow-up letters, audit tools, and annual reports.
• Monitoring performance reports from delegated entities in collaboration with the Delegation Oversight Analyst.
• Developing corrective action plans for deficiencies and tracking their completion.
• Assisting with Delegation Oversight Committee meetings.
• Working with the Manager to develop and maintain assessment tools, policies, and reporting templates.
• Preparing delegation summary reports for submission to the EQIC and/or UM Committees.
• Participating in Joint Operation Committees (JOCs) for delegated groups.
• Supporting preparation for CMS, State Medicaid, NCQA, and other regulatory audits.

Job Qualifications

Required Education

Completion of an accredited LVN or LPN program.

Required Experience

• At least two years of Utilization Review experience.
• Knowledge of audit processes and applicable regulations.

Required License, Certification, and Association

Active, unrestricted LVN or LPN license in good standing in California.

Preferred Education

Completion of an RN program or a bachelor’s degree in Nursing.

Preferred Experience

• Three years of NCQA, CMS, and/or Medicaid UM auditing experience.
• Experience in delegation oversight and knowledge of federal and state regulations.

Preferred Certifications

• Certified Clinical Coder
• Certified Medical Audit Specialist (CMAS)
• Certified Case Manager (CCM)
• Certified Professional Healthcare Management (CPHM)
• Certified in Healthcare Quality (CPHQ)

Interested Molina employees should apply via the intranet. Molina Healthcare offers competitive benefits. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $128,519 annually. Compensation varies based on location, experience, education, and skills.

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Healthcare Provider
• Industry: Human Resources Services