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Delegation Oversight Nurse
100 North Sepulveda Blvd. El Segundo, California 90245 | Contract
The primary responsibilities for the position include:
- Independent use of criteria to determine if medical groups are compliant with regulatory, legislative and Blue Shield mandated requirements
- Ability to develop and implement Corrective Action Plans (CAP) for medical groups that are out of compliance with delegated responsibilities, with timely follow up actions of CAP
- Develop and implement recommendations for improvement of quality and cost savings
- Ability to interpret statistics and plan for actions taken to improve utilization management
- Ability to stay current on regulatory changes and industry requirements.
- Participate in industry collaborative teams as needed.
- Respond to questions from Medical Groups/IPAs and provided needed guidance.
- Ability to design and implement tools and materials that are compliant with regulatory, legislative and Blue Shield mandated requirements
- Ability to design work plans and workflows to facilitate the audit, quality and cost of healthcare initiatives
- Collaborate with internal business partners relating to Medical Groups/IPAs
Key attributes for an individual to be successful in this position include being:
- Highly motivated
- Ability to work independently
- Action/results oriented
- Strong interpersonal and negotiation skills
- Strong verbal and written communication skills
- Intermediate level computer skills
- Strong organizational skills
Job Required Education/Experience Requirements:
- Current California RN license and five to seven plus years relevant experience or equivalent combination of education and experience.
- Generally requires B.A. degree or equivalent.
- In-depth knowledge of concepts, practices and procedures within the healthcare field, especially HMO.
- Strong understanding of NCQA, CMS, and DMHC regulations and audit requirements.
- Good clinical documentation and computer skills.
- Strong communication and negotiation skills.
- Previous experience in auditing strongly preferred.