UM LVN Delegation Oversight Nurse Remote based in CA

Molina Healthcare; San Francisco (CA); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare provider is seeking a Delegation Oversight Nurse to ensure compliance with NCQA, CMS, and State Medicaid requirements while managing delegated activities and quality improvement. This role offers a competitive salary and requires a strong background in utilization review and nursing qualifications, fostering a commitment to healthcare excellence.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

• Minimum two years Utilization Review experience required.
• Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse in good standing is necessary.
• Three years’ experience in UM auditing preferred.

Responsibilities

• Coordinates, conducts, and documents pre-delegation and annual assessments.
• Develops corrective action plans when deficiencies are identified and documents follow-up.
• Assists in preparation of documents for CMS, State Medicaid audits.

Skills

Audit processes

Knowledge of state regulations

Knowledge of federal regulations

Education

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program

Completion of an accredited Registered Nurse (RN) Program

Tools

Health care quality certification

Job description

JOB DESCRIPTION

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.

KNOWLEDGE/SKILLS/ABILITIES

The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant 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. This includes, but is not limited to:

• Coordinates, conducts, and documents pre-delegation and annual assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
• Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement as needed.
• Works with Delegation Oversight Analyst on monitoring of performance reports from delegated entities.
• Develops corrective action plans when deficiencies are identified, and documents follow up to completion.
• Assists with meetings of the Delegation Oversight Committee.
• Works with the Delegation Oversight Manager to develop and maintain delegation assessment tools, policies, and reporting templates.
• Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees.
• Participates as needed in Joint Operation Committees (JOC's) for delegated groups.
• Assists in preparation of documents for CMS, State Medicaid, NCQA, and/or other regulatory audits as needed.

JOB QUALIFICATIONS

Required Education

Completion of an accredited Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program

Required Experience

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

Required License, Certification, Association

Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse in good standing.

Preferred Education

Completion of an accredited Registered Nurse (RN) Program or a bachelor’s degree in Nursing.

Preferred Experience

• Three-year NCQA, CMS, and/or state Medicaid UM auditing experience.
• Three years’ experience in delegation oversight process and working knowledge of state and federal regulations.

Preferred License, Certification, Association

• Active and unrestricted Certified Clinical Coder
• Certified Medical Audit Specialists (CMAS)
• Certified Case Manager (CCM)
• Certified Professional Healthcare Management (CPHM) Certified Professional in Health Care Quality (CPHQ)
• or other healthcare
• or management certification

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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

Pay Range: $77,969 - $128,519 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.