Responsibilities
SUMMARY: The Delegation Oversight Nurse performs activities to assure compliance with Health Plan requirements. The Nurse will manage activities to meet health plan requirements in areas such as routine reporting, ad hoc reporting, annual oversight audit preparation, annual audit oversight completion, response to CAPs, and follow-up with medical groups to assure CAP implementation and compliance. Performs activities to promptly, efficiently, and accurately complete all health plan, state, federal, and other regulatory compliance processes with minimal to moderate supervision. Develop strong and positive working relationships with Health Plan representatives, clinical operations, and Medical Staff Services. Has a strong command of regulatory and accrediting requirements and health plan requirements. The Delegation Oversight Nurse works closely with business leaders in the development and implementation of external vendor initiatives aligned with the plan's business, compliance, and performance improvement strategies. The role will support the Compliance Program to ensure compliance with Federal and State laws and regulations (Centers for Medicare and Medicaid Services, Department of Managed Health Care, Department of Health Care Services, CA Department of Insurance), contract provisions, accreditation standards, and internal policies and procedures.
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Qualifications
EDUCATION and/or EXPERIENCE: Associate degree required, Bachelor's preferred. Minimum 3 years' experience in Medical Management (Utilization Management, Appeals and Grievances, and/or Concurrent Review). Over 2 years of experience in a health plan or healthcare auditing, compliance and/or operations. Awareness and experience with HIPAA requirements for healthcare communications preferred. Familiarity with developing and implementing auditing and monitoring processes across systems, internal areas, and first-tier downstream-related entities (FDRs). Knowledge of Compliance Program principles to include analyzing risk assessments, performing audits, contracting, creating reports, educating and following up with the business area to ensure processes exist to demonstrate compliance with Federal and State requirements.
CERTIFICATES, LICENSES, AND REGISTRATIONS: Current and unrestricted Licensed Practical Nursing or Licensed Vocational Nurse certificate from an accredited Nursing Program in California. Registered Nurse (RN) preferred/desired.
ESSENTIAL FUNCTIONS:
- Oversight of delegated and compliance operations with health plans.
- Timely follow-up and completion of necessary follow-up action that may include, educational letters, training, corrective action plan (CAP), concurrent review, and any additional audits.
- Coordination and scheduling of various audits.
- Serve as a regulatory resource person and trainer to staff regarding regulatory requirements, health plan standards, and processes.
- Maintain efficient and accurate records.
- Actively participate in both internal & external meetings and webinar training sessions.
- Tracking & collection of incoming required UM documents.
- Ensure timeliness of required Health Plan reports.
- Identify patterns, deficiencies, and trend audit findings.
- Review denial letters for clinical criteria and appropriate language.
- Coordinates and gathers documentation to respond to audits conducted either internally or externally.
- Prepare delegate compliance reports and tracking logs.
- Assist with the policy and procedures updates, as necessary.
- Support the Delegation Oversight Analyst in the development and validation of reports regarding audits, including analyzing, tracking, and monitoring compliance with regulatory and health plan requirements.
- Other duties as assigned, as needed.
THIS OPPORTUNITY OFFERS THE FOLLOWING:
Challenging and rewarding work environment
Growth and Development Opportunities within UHS and its Subsidiaries
Competitive Compensation
ABOUT UNIVERSAL HEALTH SERVICES: One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com
EEO STATEMENT: All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
We believe that diversity and inclusion among our teammates is critical to our success.
AVOID AND REPORT RECRUITMENT SCAMS: At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.
If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
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