RN, Delegation Oversight Auditor

Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges. Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their very best. If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure. About this role: 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 Job Function & Responsibilities 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. • 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 MINIMUM QUALIFICATIONS Education & Experience: • High School Graduate or General Education Degree (GED): Required • Bachelor's Degree (four-year college or technical school) Required • 5+years of experience in a clinical setting performing Utilization Review, Delegation Oversight Auditing UM activities required • 5 + years NCQA, CMS, and/or state Medicaid UM auditing experience required • 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 required. KNOWLEDGE, SKILLS & ABILITIES Preferred Qualifications: • Active, current, and unrestricted California License as a Registered Nurse (RN) • Project Management experience • 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.[HR1.1] Technology & Software Skills : Advanced computer skills in MS Office products. Certifications & Licenses: • A valid and current Driver's License, Auto Insurance, and professional licensure(s) • Certified Medical Audit Specialists (CMAS) preferred • Certified Professional Healthcare Management (CPHM) preferred • Certified Professional in Health Care Quality (CPHQ) preferred • Certified Professional in Utilization Review (CPUR) preferred • Certified Case Manager (CCM) preferred The estimated pay range for the position is: $100,000.00 - $150,000.00 The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in. 700