As the Delegation Oversight Nurse - Auditor, you will be responsible for the oversight of the clinical operations at Clever Care Health Plan. You will lead the company’s efforts to meet regulatory and compliance requirements as you collaborate with internal departments and delegated entities. As the Delegation Oversight Nurse - Auditor, you will be the expert and go-to person on all clinical Audit & Compliance requirements.

Functions & Job Responsibilities

Audit:

• Perform clinical file audits of delegated entities utilization and case management activities
• Perform data validation of utilization management universes of delegated entities
• Manage multiple internal and external audits and related projects.
• Manage multiple audits and related projects.
• Develop, implement, and manage corrective action plans.
• Monitor, analyze, aggregate and report on data reported to the Plan.
• Provide leadership and direction in communicating and monitoring policies, procedures, practices, programs, and processes.
• Participate and/or lead CMS Mock-Audits and train associates.
• Lead clinical audit activities and report results to leadership team.
• Collaborate on the clinical audit program for the Plan.
• Other audit & compliance special projects.

Other:

• Maintain an up-to-date knowledge of UM audit & compliance requirements.
• Collaborate with other departments on issues, audits and corrective actions.
• Consult with General Counsel/lawyer, as needed, to identify and resolve legal issues and concerns.
• Perform functions according to established policies and procedures, regulatory requirements, and applicable professional standards.
• Provide customers, internal and external, with professional service and demonstrates core and leadership behaviors.
• Additional duties, as assigned.

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Qualifications

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 onsite audit work.

Experience/Job Knowledge:

• Minimum 3-5 years Utilization Management experience in a HMO setting, preferred.
• Minimum 3-5 years of Medicare Audit or Compliance experience.
• Advanced knowledge of Medicare Advantage CMS and California DMHC regulations.
• Advanced knowledge of HIPAA regulations required.

Skills:

• Strong organizational skills: Ability to multitask and problem solving.
• Experienced at interfacing with national and regional CMS offices.
• Presentation skills for training large and small groups.
• Excellent verbal and written communication skills and ability to maintain positive relations with Plan partners.
• Analytical and critical thinking skills are required.
• Exhibit initiative and ability to assume responsibility and maintain confidentiality.
• Computer skills and experience with Microsoft Office Products.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.