JOB DESCRIPTION
Job Summary
Responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including delegation standards and requirements contained in the delegation agreement.
KNOWLEDGE/SKILLS/ABILITIES
The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. We are looking for LVN's with at least 4 years of UM experience, NCQA accreditation andknowledge of InterQual / MCG guidelines. Excellent computer multi-tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times. Experience with Appeals, Auditing, Prior Authorization, Compliance and Quality will be a good fit for this position. Further details to be discussed during our interview process.
CA located – Remote position
- Coordinates, conducts, and documents pre-delegation and annual assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
- Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement as needed.
- Works with Delegation Oversight Analyst on monitoring of performance reports from delegated entities.
- Develops corrective action plans when deficiencies are identified, and documents follow up to completion.
- Assists with meetings of the Delegation Oversight Committee.
- Works with the Delegation Oversight Manager to develop and maintain delegation assessment tools, policies, and reporting templates.
- Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees.
- Participates as needed in Joint Operation Committees (JOC's) for delegated groups.
- Assists in preparation of documents for CMS, State Medicaid, NCQA, and/or other regulatory audits as needed.
JOB QUALIFICATIONS
Required Education
Completion of an accredited Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program
Required Experience
- Minimum two years Utilization Review experience.
- Knowledge of audit processes and applicable state and federal regulations.
Required License, Certification, Association
Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse in good standing.
Preferred Education
Completion of an accredited Registered Nurse (RN) Program or a bachelor’s degree in Nursing.
Preferred Experience
- Three-year NCQA, CMS, and/or state Medicaid UM auditing experience.
- Three years’ experience in delegation oversight process and working knowledge of state and federal regulations.
Preferred License, Certification, Association
- Active and unrestricted Certified Clinical Coder
- Certified Medical Audit Specialists (CMAS)
- Certified Case Manager (CCM)
- Certified Professional Healthcare Management (CPHM) Certified Professional in Health Care Quality (CPHQ)
- or other healthcare
- or management certification
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
United States
