Delegation Oversight Nurse - Auditor at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Who is Alignment Healthcare?

• Socially responsible


• Technologically enabled


• Concierge care


• Transformation


• Servant leadership

We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.

We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.

Position Summary: 

The Delegation Oversight Nurse is responsible for the oversight of clinical operations for Alignment Healthcare’s Delegated Entities, IPAs, vendors and subcontracted providers. Responsible for serving as a point of contact, coordinating, and collaborating with UM delegated entities, promote and maintain favorable working partnerships to improve delivery and quality of healthcare. In this capacity, the Delegation Oversight Nurse leads, coordinates and participates in delegation oversight audits and monitoring according to regulatory and contractual requirements.

General Duties/Responsibilities:

(May include but are not limited to)

• Manage multiple audits and related projects, make judgements around objectives and scope, ensure effective and efficient audit execution.


• Monitor, analyze data reported, and identify non-compliance with regulatory requirements and issue corrective action plans as required.


• Develop, implement, and manage corrective action plans (CAP's)/recommendations when deficiencies are identified and document follow-up to completion.


• Act as an operational expert and interventionist through communication, education and design of programs and strategies to assist delegated entities to meet regulatory and accrediting standards.


• Aggregate and analyze audit findings into a reportable format and report to appropriate departments.


• Evaluate and validate Utilization Management required reporting to ensure continued compliance with delegated responsibilities.


• Develop, prepare, and analyze reports for management review and present to various levels of management and committees.


• Participate in various committee meetings as needed.


• Assist with planning and implementation of formal education sessions to delegated partners to address non-compliance issues.


• Collaborate with internal business units to support reporting requests and maintain reports.


• Works with the Delegation Oversight Director to develop and maintain delegation audit tools, policies, and reporting templates.


• Assist with preparation of documents for CMS and/or other regulatory audit audits as needed.


• Other projects and duties as assigned.

Supervisory Responsibilities:

None

Minimum Requirements:

 1. Minimum Experience:

• Minimum 3-5 years Utilization and Case Management experience in an HMO, Medicare Advantage HMO and/or IPA setting, with in-depth knowledge of all aspects of managed care operations.


• 2 years of experience conducting oversight audits of delegated entities and/or ancillary providers.


• Strong knowledge of managed care principles and delivery systems, medical management process, accreditation and regulatory standards, delegated oversight processes, and workflow systems.


• Knowledge of managed care compliance, Medicare Advantage Health Plan, CMS regulations and NCQA standards.

 2. Education/Licensure:

• Active, unrestricted State License for Registered Nurse (RN) or Licensed Vocational Nurse (LVN).


• Associate or bachelor’s degree in nursing or equivalent preferred.


• Valid driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for work away from the primary office 20% of the time or more.

 3. Knowledge/ Skills:Self-starter and able to work independently.

• Knowledge of audit processes and applicable federal regulatory and accredited standards.


• Must possess a high level of organizational skills to maintain accurate records and documentation.


• Attention to detail with analytical and problem-solving capabilities.


• Ability to take initiative and see tasks to completion.


• Computer skills and experience with Microsoft Office Products.


• Excellent verbal and written communication skills and able to maintain positive relations with internal and external partners at all levels.


• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) regulations.


• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.


• Ability to travel to perform onsite audits.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

•  While performing the duties of this job, the employee is regularly required to talk or hear.


• The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.


• The employee frequently lifts and/or moves up to 10 pounds.


• Specific vision abilities required by this job include close vision and the ability to adjust focus.