Delegation Oversight Nurse, RN (Remote)

Position Summary/Position

Under the direction of the department leaderhship, the Delegation Oversight Nurse, RN is responsible for oversight of clinical operations for the IPA/Plan Delegates. In this capacity, the Delegation Oversight Nurse, RN 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.

Major Functions (Duties and Responsibilities)

1. Serve as main clinical liaison to IPA/Delegate to assist with interpreting, clarifying, and educating on IEHP policies and procedures, Utilization and Case management processes and reporting requirements as they apply to specific IEHP 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 (IEHP, 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:
   a. IEHP Direct membership and IEHP Behavioral Health
   b. Assigned IPA’s
   c. Delta Dental
   d. American Specialty Health Plan (ASH - Acupuncture)
   e. Complex Case Management cases – all IPA’s; all LOB’s
   f. Support Delegation Oversight Manager with internal Quality Assurance audits
Take lead to coordinate IPA trainings that may include the following areas:
   a. UM
   b. CM/CCM
   c. CCS
Act as clinical resource for new team member training on Delegation Oversight functions
 a. Responsible for working with the plan’s Provider Services Dept. to schedule regulatory audits.
 b. 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
6. Assist and contribute to the development of internal Medical Management Policy and Procedure Manuals.
7. Maintain comprehensive files for all IPA/Delegate correspondence and monitoring activities, tracking trends and outliers.

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.

Professional Licenses

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN

Drivers License Required

Knowledge Requirement

Knowledge in NCQA standards, DHCS, CMS, and DHMC regulatory requirements. Have working knowledge to adult learning methods.

Skills Requirement

Strong computer skills. Must have excellent verbal and written communication skills. Must possess high level of organizational skills to maintain accurate records and documentation.

Abilities Requirement

Self-starter and able to work independently. Able to maintain positive relationships with internal and external customers at all levels. Ability to effectively present new information.

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.