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Delegation Oversight Clinical Auditor RN II

Job Category:  Clinical
Department:  Enterprise Performance Optimization
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8496

 

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 in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Delegation Oversight Clinical Auditor RN II is responsible for ensuring that delegates contracted to perform Utilization Management (UM) functions on behalf of LA Care (LAC) is in compliance with all UM regulatory requirements and new legislation through the maintenance of required policies/procedures/workflows/ processes/audit tools necessary to meet the requirements. It is expected that the Clinical Auditor will utilize a rapid team approach for needed improvements identified through external audits of delegated entities.  This position assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit unit ensuring that departmental/divisional and organizational goals are accomplished through overseeing and facilitating compliance of the Plan Partners, Participating Provider Groups (PPG),  Specialty Health Plans (SHP), and contracted provider network as managed by the Delegation Oversight Department. It is responsible, as part of the oversight team, for ensuring compliance of the Plan Partners and/or Participating Physician Groups (PPG) to regulatory, contractual and L.A. Care requirements. This position is responsible for performing annual and focused audits. This position also acts as a liaison between the Plan Partners and PPGs and L.A. Care Health Plan regarding UM issues. The position assists in improving access and utilization performance of Plan Partners and PPGs by being a resource for best practices and providing continuous feedback. Additionally, the oversight responsibility of this position includes reporting to management and providing consultation/instructional/coaching recommendations to improve overall compliance of Plan Partners and PPGs with all regulations and standards.

Duties


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. Stay abreast of new UM legislation, regulations, or other changes impacting UM in order to put processes in place for 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. Assures 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. Present 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.   

Education Required

Associate's Degree in Nursing

Education Preferred

Bachelor's Degree in Nursing

Experience


Required:
At least 3-5 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management.

Skills

Required:
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 Skills.

Licenses/Certifications Required

Registered Nurse (RN) - Active, current and unrestricted California License

Licenses/Certifications Preferred

Required Training

Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

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