- Full Time/Contract
- Managed Care Nursing
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company To Work For , "Favorite Training Program , and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
Delegation Oversight Nurse (RN)
Under the direction of the Delegation Oversight Manager, the Delegation Oversight Nurse, RNis responsible for oversight of clinical operations for the IPA/Plan Delegates. In this capacity, the Delegation Oversight Nurse works directly with IPA/Plan Delegate Administrators, Medical Directors, and IPA staff to ensure accurate and timely education, dissemination and adherence to all Health Plan and mandated Regulatory requirements to assigned IPA/Plan Delegates.
1) Serve as main clinical liaison to IPA/Delegate to assist with interpreting, clarifying and
educating on policies and procedures, Utilization and Case management processes and reporting requirements as they apply to specific Members.
2) Serve as a resource person and trainer to IPA/Delegate’s staff regarding Plan and regulatory requirements and forms. Assist other medical services departments and staff within the organization in regard to delegated medical services activities as required.
3) Attend Joint Operations Meetings (JOM) as Medical Services liaison. Responsible for
documentation, formatting and dissemination of minutes, as required.
4) Accountable for oversight of IPA activity through monthly collection, analysis, audit and tracking of data/reports and case files to ensure IPA meets regulatory standards
(NCQA, CMS, and DHCS). Collaborate with the Plan Medical Director regarding IPA/Delegate’s deficiencies and non-compliance issues identified during the monthly audits with necessary follow-up action; such as, educational letters, training, corrective action plan (CAP), concurrent review, etc.
5) Responsible for conducting monthly IPA/Delegate denials, approvals, CCS, and care
management file audits and annual Medical Management audits and for reporting results to the IPA/Delegate and Plan.
Specific scope of auditing may include the following areas:
i) Direct membership and Behavioral Health
ii) Assigned IPA’s
iii) Delta Dental
iv) American Specialty Health Plan (ASH – Acupuncture)
v) Complex Case Management cases all IPA’s; all LOB’s
vi) Support Delegation Oversight Manager with internal Quality Assurance audits
Take lead to coordinate IPA trainings that may include the following areas:
Act as clinical resource for new team member training on Delegation Oversight functions
6) Responsible for working with the plan’s Provider Services Dept. to schedule regulatory
7) Actively participate in both internal and external meetings, such as, Delegation Oversight,
Utilization Management Subcommittee, Denial Related Grievance Review, and in other internal and external meetings as assigned, including preparation and presenting of reports as required. IPA Liaison Job Description
8) Any other duties as required to ensure successful Plan and Delegate operations.
9) Assist and contribute to the development of internal Medical Management Policy and
10) Maintain comprehensive files for all IPA/Delegate correspondence and monitoring activities, tracking trends and outliers.
11) Ensure the privacy and security of PHI (Protected Health Information) as outlined in policies and procedures relating to HIPAA compliance.
REQUIREMENTS; MINIMUM QUALIFICATIONS
Possession of a valid unrestricted RN license issued by the State of California. Possession of a valid State of California driver’s license and automobile insurance.
- Three (3) or more years of utilization and case management experience in an HMO and IPA setting with in-depth knowledge of all aspects of managed care operations.
- Knowledge in NCQA standards, DHCS, CMS, and DHMC regulatory requirements.
- Strong computer skills.
COMPENSATION | POSITION CLASSIFICATION
- Commensurate with Experience
- Full Time | Contract Assignment