Delegation Oversight Clinical Auditor RN II

Salary Range

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

About the role

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Responsibilities

• Continually ensures delegate compliance with UM Policies/Procedures, Letter Templates, Workflows, Processes, and Audit Tools in compliance with all regulatory requirements/new legislation.
• Works collaboratively with Regulatory Affairs & Compliance.
• Prepares the Delegation Oversight Clinical Audit team for internal audits and for conducting PP/PPG audits, developing mechanisms for tracking/ trending of progress for UM/PPG (internal) and PP (external) for compliance with UM standards, and identities system/individual areas for improvement through these processes.
• Prepares the Delegation Oversight Department for review by external regulatory bodies.
• Ensures that the Delegation Oversight Department is continually prepared for external review with staff daily work conducted in a manner that meets regulatory requirements.
• Ensures that the Delegation Oversight Clinical Audit unit functions as a team in preparing needed documents for an external review.
• Completes annual, focused and periodic audit activities timely and thoroughly including identification of deficiencies, response to mitigation, review and response to CAPs.
• Identifies repeat deficiencies.
• Affirms audit documentation is clear, complete and accurate.
• Completes periodic monitoring of PP or PPG performance in critical deficiency areas.
• Completes follow-up audits and related reports and recommendations.
• Identifies options to assist PP or PPGs with continued or significant deficiencies.
• Updates audit tools to meet regulatory, contractual and L.A. Care requirements.
• Develops and conducts ongoing monitoring activities including but not limited to file reviews and letters and supplemental reports.
• Presents summary results to L.A. Care's UM Committee.
• Communicates with assigned PP and PPGs on an ongoing basis.
• Develop mechanism to track and trend progress of PP and PPG's compliance to UM standards and identify system wide issues.
• Maintains confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.
• Assists co-workers with special projects or work volume as required.
• Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions.
• Actively identifies and makes recommendations to supervisor ideas to improve the quality effectiveness and efficiency of departmental and health services functions.
• Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner.
• Provides training, education and consultation as necessary to PP and PPGs.
• Collaborates with other Clinical Auditors on identifying topics and developing agendas for the JOM's and PP visits/communication.
• Develops and implements procedures to assure compliance with care coordination and documentation of linked and carved out services.
• Conducts Interrater Reliability Testing (referral management and oversight) for new staff/physicians and annually or as needed for existing staff/physicians.
• Works with other departments as necessary to facilitate teamwork for creating and/or improving interdepartmental processes to meet regulatory requirements.

Qualifications

• Education Required: Associate's Degree in Nursing
• Education Preferred: Bachelor's Degree in Nursing
• Experience Required: At least 7 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management.

Skills

• Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers.
• Ability to manage and organize large volumes of data.
• Knowledge of accreditation entities and their requirements.
• Excellent verbal and written communication skills and excellent interpersonal skills.
• Good working knowledge of regulatory requirements/standards.
• Ability to work independently.
• Ability to solve complex issues and identify creative solutions.
• Computer ease & literacy with Word, Excel, PowerPoint

Benefits

L.A. Care Offers a Wide Range Of Benefits Including Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental and VisionWellness ProgramVolunteer Time Off (VTO)