RN, Delegation Oversight Auditor

Job not on LinkedIn

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $100k - $150k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Gold Coast Health Plan

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2011

At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

📋 Description

• Responsible for continuous quality improvements within the Delegation Oversight program • Leads coordination and performance of pre-delegation and annual audits for delegates related clinical program oversight • Manage Clinical Compliance Program delegation oversight audits, including pre-audit letters, audit reporting requirements, and audit tools • Coordinate audit scheduling, develop audit findings, aggregate and analyze audit results, and write audit reports including corrective action plans required of delegates • Maintain accurate records of all delegation oversight audits and ensure deadlines are met • Oversee and assist in revising delegation oversight audit tools in accordance with ICE, NCQA, Plan policies and procedures, and State and Federal guidance • Provide training, education, and consultation to delegates • Collaborate with Delegation Oversight staff and Health Services Department to identify topics and develop agendas for Joint Operations Meetings with delegates • Attend and present at Compliance Committee, Quality Improvement Committee, and other meetings as appropriate • Direct and create memos, charts, and graphs for committee presentations • Stay informed about developments in the delegation oversight field through professional resources, associations, conferences, seminars, and other information sources • Oversee delegated activities to ensure compliance with NCQA, CMS, State Medicaid requirements, and delegation agreement standards • Assist in developing and implement departmental objectives supporting organizational strategies • Maintain effective communication with organizational levels and external organizations • Perform other duties as assigned

🎯 Requirements

• High School Graduate or General Education Degree (GED): Required • Bachelor's Degree (four-year college or technical school) Required • 5+years of experience in a clinical setting performing Utilization Review, Delegation Oversight Auditing UM activities required • 5 + years NCQA, CMS, and/or state Medicaid UM auditing experience required • 3 + years of experience in supporting, training, and mentoring others in Managed Care clinical functions such as prior authorization, medical record reviews, member grievances, or quality reviews required • Advanced computer skills in MS Office products • A valid and current Driver's License, Auto Insurance, and professional licensure(s) • Active, current, and unrestricted California License as a Registered Nurse (RN) (preferred) • Project Management experience (preferred) • Certified Medical Audit Specialists (CMAS) certification (preferred) • Certified Professional Healthcare Management (CPHM) certification (preferred) • Certified Professional in Health Care Quality (CPHQ) certification (preferred) • Certified Professional in Utilization Review (CPUR) certification (preferred) • Certified Case Manager (CCM) certification (preferred)