Delegation Oversight Nurse, LVN (Hybrid remote options)

Date: Nov 17, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5869 

 

Position Summary/Position

 

Under the direction of the Delegation Oversight Manager, the Delegation Oversight Nurse, LVN is responsible for oversight of clinical operations for the delegated IPA and subcontracted providers. In this capacity, the Delegation Oversight Nurse, LVN works directly with IEHP and delegated IPA Administrators, Medical Directors, and IPA staff to ensure accurate and timely dissemination of all IEHP and mandated Regulatory requirements to all IPA and subcontracted providers.

Major Functions (Duties and Responsibilities)

 

1. Serve as liaison to delegated IPA and subcontracted providers to assist with interpreting IEHP Policies and Procedures and referral processes as they apply to IEHP Members.
2. Serve as a regulatory resource person and trainer to IPA’s staff regarding IEHP and regulatory requirements, standards and forms.  Assist other medical services departments and staff within the organization in regards to delegated medical services activities as required.
3. Attend Joint Operations Meetings (JOM) between delegated IPA and IEHP.  Responsible for documentation, formatting and dissemination of minutes, as required.
4. Oversight of IPA activity through monthly collection and tracking of data/reports.  Collaborate with IEHP Medical Director regarding IPA and subcontracted providers’ deficiencies and non-compliance issues identified during the monthly audits.  Timely follow-up and completion of necessary follow-up action that may include, educational letters, training, corrective action plan (CAP), concurrent review, and any additional audits, etc.
5. Conduct comprehensive monthly IPA denial and care management file audits and annual Medical Management audits, prepare and report results to the IPA and IEHP.
6. Work with the IEHP’s Provider Services Dept. to schedule regulatory audits.
7. Active participation 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.
8. Assist in the development of internal Medical Management Policy and Procedure Manuals.
9. Maintain comprehensive files for all IPA/Delegate correspondence and monitoring activities.

Experience Qualifications

 

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.

Education Qualifications

 

High school diploma or GED required.

Professional Licenses

 

Possession of an Active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement

 

Knowledge in NCQA standards, DHCS, CMS, and DHMC regulatory requirements.

Skills Requirement

 

Must have excellent communication skills and able to maintain positive relationships with internal and external contacts at all levels.

Must possess high level of organizational skills to maintain accurate records and documentation. 

Abilities Requirement

 

Self starter and able to work independently.

Commitment to Team Culture

 

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

 

Starting Salary: $57,948.80  - $73,860.80  

Pay rate will commensurate with experience

 

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

 


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles