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

ClickJobs.io; Sterling Heights (MI); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare organization is seeking a Delegation Oversight Nurse to ensure compliance with NCQA, CMS, and State Medicaid requirements. The role involves overseeing delegated activities, conducting assessments, and preparing documentation for audits. Candidates must possess a valid LVN or LPN license and have experience in Utilization Review. Join a dynamic team dedicated to quality improvement in healthcare.

Qualifications

• At least two years of Utilization Review experience.
• Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse license.

Responsibilities

• Oversees delegated activities to ensure compliance with NCQA, CMS, and State Medicaid requirements.
• Conducts and documents pre-delegation and annual assessments.
• Develops corrective action plans for deficiencies.

Skills

Utilization Review

Audit Processes

Regulatory Compliance

Education

LVN or LPN Program

RN Program

Bachelor’s Degree in Nursing

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 ensures Molina Healthcare's UM delegates comply with all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare's business needs. Supports the Delegation Oversight Manager with various duties, including:

• Conducting and documenting pre-delegation and annual assessments to meet regulatory requirements.
• Distributing audit results and follow-up correspondence.
• Monitoring performance reports from delegated entities with the Delegation Oversight Analyst.
• Developing corrective action plans for deficiencies and following up on their resolution.
• Participating in meetings of the Delegation Oversight Committee.
• Assisting in developing and maintaining assessment tools, policies, and reporting templates.
• Preparing delegation summary reports for submission to relevant committees and agencies.
• Participating in Joint Operation Committees (JOCs) for delegated groups.
• Preparing documentation for audits by CMS, State Medicaid, NCQA, and other regulators.

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 State Licensed Vocational Nurse or Licensed Practical Nurse license in good standing.

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 regulatory compliance.

Preferred Licenses and Certifications

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

Current Molina employees interested in this role should apply via the intranet. Molina Healthcare offers competitive benefits and compensation. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $128,519 annually. Actual compensation may vary based on location, experience, education, and skills.