RN, Delegation Oversight Auditor

Work Culture: GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together. GCHP promotes a flexible work environment. Employees may work from home or in the GCHP office for all or part of their regular workweek (see disclaimer). GCHP focuses on 5 Core Values in the workplace: Integrity Accountability Collaboration Trust Respect Disclaimers: Flexible work schedule depends on job duties, department, organization, or business need. Gold Coast Health Plan will not sponsor applicants for work visas. POSITION SUMMARY Under the general direction of the Compliance Director, the RN, Delegation Oversight Auditor leads, coordinates, and participates in delegation oversight audits of Gold Coast Health Plan's vendors, service providers, and delegated subcontracted providers according to regulatory and contractual requirements. The role includes acting as a liaison between subcontracted providers and overseeing the delegation clinical oversight audit process, developing reports, analyzing, tracking, and trending audit findings. Additionally, the position supports the compliance department by conveying information, problem-solving issues, providing guidance on regulatory requirements, and assisting with audit preparation and coordination. Amount of Travel Required: 30 - 40% Work Schedule: Occasional travel to multiple sites and locations. ESSENTIAL FUNCTIONS Reasonable Accommodations Statement To perform this job successfully, an individual must be able to perform each essential function satisfactorily, with or without reasonable accommodations. Reasonable accommodations may be provided to enable qualified individuals with disabilities to perform these functions. Essential Functions: Perform administrative duties requiring analytical, organizational, and technical skills; exercise discretion and judgment appropriate for the position; minimal supervision required; management level position. Lead coordination and performance of pre-delegation and annual audits related to clinical program oversight. Manage Clinical Compliance Program delegation oversight audits, including pre-audit letters, reporting, and audit tools. Coordinate audit scheduling, develop findings, analyze results, and write reports with corrective action plans. Maintain accurate records of all audits and ensure deadlines are met. Oversee and assist in revising audit tools in accordance with standards set by ICE, NCQA, policies, procedures, and regulatory guidance. Provide training, education, and consultation to delegates. Collaborate with staff and departments to identify topics and develop agendas for meetings with delegates. Attend and present at compliance and quality improvement meetings; prepare memos, charts, and graphs for presentations. Stay informed on delegation oversight developments through resources, associations, conferences, and seminars. Ensure delegated activities comply with NCQA, CMS, State Medicaid requirements, and delegation standards. Assist in developing and implementing departmental objectives aligned with organizational strategies. Perform other duties as assigned. POSITION QUALIFICATIONS Competency Statements: Analytical Skills: Use reasoning to solve problems. Technical Aptitude: Understand complex technical topics. Problem Solving: Proactively address work-related issues. Communication, Written: Communicate clearly in writing. Communication, Oral: Effectively communicate verbally. Diversity Oriented: Work effectively with diverse groups. Ethical Conduct: Demonstrate professional integrity. Judgment: Make sound decisions based on information. Interpersonal Skills: Get along well with others. Relationship Building: Develop effective relationships. Presentation Skills: Present information effectively. Skills & Abilities Requirements: Education: High School/GED required; Bachelor's Degree in BSN, Business, Health Sciences, or Managed Care preferred. Experience: 5+ years in clinical settings with Utilization Review and Delegation Oversight Auditing; 3+ years supporting, training, and mentoring in Managed Care functions. Computer Skills: Advanced proficiency in Microsoft Word, Excel, Access, and PowerPoint. Licenses: Active, unrestricted California RN license. Preferred: Experience in Project Management. Certifications: CMAS, CPHM, CPHQ, CPUR, CCM preferred.

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