UM LVN Delegation Oversight Nurse Remote based in CA

Lensa; Long Beach (CA); Remote; USD 68,000 - 124,000; Full time

Job summary

A leading healthcare provider is seeking a Delegation Oversight Nurse to ensure compliance with state and federal regulations. This remote role requires strong analytical skills, LVN licensure, and experience in Utilization Management. The successful candidate will coordinate assessments, develop corrective action plans, and assist in regulatory audits.

Qualifications

• Active, unrestricted State Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) in good standing.
• Minimum two years of Utilization Review experience.
• Knowledge of audit processes and applicable regulations.

Responsibilities

• Coordinate, conduct, and document pre-delegation and annual assessments.
• Develop corrective action plans when deficiencies are identified.
• Assist with meetings of the Delegation Oversight Committee.

Skills

Analytical Thinking

Multi-tasking

Computer Knowledge

Education

Completion of an accredited LVN or LPN program

Completion of an accredited RN program or a bachelor’s degree in nursing

Tools

Knowledge of InterQual / MCG guidelines

Job description

UM LVN Delegation Oversight Nurse Remote based in CA

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Job Description

Job Summary

The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant with all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. We are looking for LVNs with at least 4 years of UM experience, NCQA accreditation, and knowledge of InterQual / MCG guidelines. Excellent computer knowledge, multi-tasking skills, and analytical thinking are important for success in this role. Productivity and quick turnaround times are essential. Experience with Appeals, Auditing, and Compliance/Quality will be advantageous. Strong UM Prior Authorization experience is highly preferred. Further details will be discussed during the interview process.

This is a remote position based in CA with work hours: Monday – Friday, 8:00 am – 5:00 pm PST.

Responsibilities

• Coordinate, conduct, and document pre-delegation and annual assessments to comply with state, federal, NCQA, and other applicable requirements.
• Distribute audit results letters, follow-up letters, audit tools, and annual reporting requirements.
• Work with the Delegation Oversight Analyst to monitor performance reports from delegated entities.
• Develop corrective action plans when deficiencies are identified and follow up until resolution.
• Assist with meetings of the Delegation Oversight Committee.
• Collaborate with the Delegation Oversight Manager to develop and maintain assessment tools, policies, and reporting templates.
• Assist in preparing delegation summary reports for submission to the EQIC and/or UM Committees.
• Participate in Joint Operation Committees (JOCs) for delegated groups.
• Help prepare documents for CMS, State Medicaid, NCQA, and other regulatory audits as needed.

Qualifications

Required Education

Completion of an accredited LVN or LPN program.

Required Experience

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

Required License

Active, unrestricted State Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) in good standing.

Preferred Education

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

Preferred Experience

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

Preferred Licenses/Certifications

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

All current Molina employees interested in this position should apply through the intranet.

Molina Healthcare offers competitive benefits and compensation. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $68,640 - $123,164 annually. Actual compensation may vary based on location, experience, education, and skills.

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Healthcare Provider