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Delegation Oversight Auditor, Nurse Specialist

Company: Heritage Provider Network
Location: Orange
Posted on: May 13, 2022

Job Description:

Job DescriptionDelegation Oversight Auditor, Nurse Specialist performs delegation oversight functions including but not limited to annual audit, focused audits and ongoing monitoring of Affiliated Medical Groups to assure the Group compliance with Regulatory, Accreditation and Health Plan requirements for Utilization Management and Case Management. Nurse Specialist will also make recommendations and issue approved CAPs and monitor the implementation of those CAPs. The Nurse Specialist will work closely with the Medical Groups, Data Analysts and Health Plan compliance team to promote compliant UM and CM processes.Requirements1. Graduate from an accredited school for Nursing2. Current and maintains California Nursing License (RN very strongly preferred)3. Three to five (3-5) years of clinical experience required4. Two to three (2-3) years of managed care experience required5. Minimum one year (1) year of UM delegation oversight audit experience with a Health Plan or large MSO required. Case Management audit experience preferred6. Demonstrated knowledge of regulatory requirements including DMHC, DHCS, CMS and NCQA requirements7. Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point)8. Typing 60 words per minutes with accuracy9. Ability to deal with responsibility with confidential matters10. Must have strong analytical, creative problem solving, and organizational skills11. Ability to work in a multi-task, high stress environment12. Ability to strategize effectively, execute within timelines, and deliver quality results13. Ability to thrive in a fast-paced environment where flexibility and being proactive are essential14. Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities15. Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics16. Must have the ability to work with all levels of management and have the ability to develop positive working relationships with different divisions in the company

Keywords: Heritage Provider Network, Orange , Delegation Oversight Auditor, Nurse Specialist, Healthcare , Orange, California

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