Share this Job

Delegation Oversight Nurse, RN (Remote)

Date: Apr 22, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 4953 

 

Position Summary/Position

 

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

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:
   i) IEHP Direct membership and IEHP 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:
   a. UM
   b. CM/CCM
   c. CCS
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 audits.
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. Assist and contribute to the development of internal Medical Management Policy and Procedure Manuals.
9. 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.

Education Qualifications

 

High school diploma or GED required.

Professional Licenses

 

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) 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. 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.

 

Starting Salary: $75,296.00  - $95,992.00  

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