Delegate Oversight Specialist

Brief Description

Harbor Health is seeking a Delegate Oversight Specialist to join their Health Plan Operations team. This role involves end-to-end oversight of delegated entities across Medicare Advantage, Medicaid, and commercial lines of business, ensuring compliance with regulatory and contractual requirements.

Position Duties & Responsibilities

• Conduct pre-delegation assessments and annual audits of delegated entities, including credentialing, utilization management (UM), claims, and member services functions.

• Monitor delegate performance against contractual standards, CMS requirements, TDI regulations, and NCQA/URAC accreditation standards.

• Maintain a comprehensive delegation oversight calendar, tracking audit cycles, reporting deadlines, and corrective action plan (CAP) milestones.

• Review and update delegation agreements in collaboration with Legal and Compliance teams to ensure alignment with current regulatory requirements.

• Lead on-site and desk audits of delegate operations; document findings with supporting evidence and issue formal audit reports.

• Develop, track, and close corrective action plans (CAPs) in response to identified deficiencies; escalate unresolved issues to leadership.

• Prepare delegates for CMS program audits (HPMS, IDAG, universe submissions) and TDI market conduct examinations.

• Compile and submit monthly, quarterly, and annual delegation performance reports to the Delegation Oversight Committee.

• Maintain organized, audit-ready delegation files including executed agreements, assessment tools, audit reports, CAPs, and attestations.

• Track and analyze delegate performance metrics — including UM turnaround times, credentialing cycle times, and claims accuracy rates — and surface trends to leadership.

• Serve as the primary point of contact for delegated entities; build collaborative relationships while maintaining appropriate oversight authority.

• Coordinate with Quality, Provider Relations, and Network Management teams on overlapping delegate performance issues.

• Support responses to regulatory inquiries or member complaints related to delegated functions.

Required & Desired Professional Skills & Experience

• Bachelor's degree in Healthcare Administration, Business, Nursing, or a related field; equivalent experience considered.

• 3+ years of experience in health plan operations, managed care compliance, audit or delegation oversight.

• Demonstrated experience conducting audits, managing CAPs, and producing formal audit reports.

• Strong organizational skills with the ability to manage multiple delegate relationships and deadlines simultaneously.

• Preferred experience with NCQA accreditation standards or TDI regulatory requirements, familiarity with HEDIS, risk adjustment, IBNR, or health plan quality programs, certification in Healthcare Compliance (CHC), Managed Care (CMCM), or NCQA Credentials Verification (CVO).

What We Offer

• Competitive salary and incentives.

• Generous PTO.

• 10 paid holidays.

• Medical, Dental, and Vision Insurance.

• 401(k) Investment Plan.

• Company Equity.