Your Role

The Delegation Oversight Utilization Management team is responsible for the organization, tracking and data entry of IPA Utilization Management audits, issues, complaints and monitoring. Identifies root cause of the problem and maintains monthly reporting that track and compare patters of delegated entities. The Delegation Operations Nurse Auditor-LVN-Experienced will report to the Manager of UMDO. In this role you will be assist in maintaining continuous quality improvement in the Utilization Management Delegation Oversight Clinical Audit ensuring that departmental and organizational goals are accomplished through oversight and facilitating Utilization Management compliance of the Plan Partners.

Your Work

In this role, you will:

• Be responsible for overseeing policy and procedure review and completing limited and less complex full desk or onsite Pre-delegation, Annual or follow-up audits /assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements.
• Act as the auditor in charge on small and less complex audits, with supervision, of Sr. management and other delegated non-clinical areas through to corrective action plan oversight.
• Research, investigate and oversee delegated entity's compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
• Educate the delegated entities and vendors on area of expertise including but not limited to claims payment management, credentialing management, financial solvency, and system controls.
• Collaborate on regulatory audits, findings responses or enforcements by regulatory agencies.
• Responsible to write Corrective Action Plans and comprehensive summaries
• Knowledge of DMHC, DHCS, CMS, Title 22 CCR, Title 28, Title 42, and Medi-Cal, Medicare processing guidelines
• Ability to effectively communicate with internal and external associates
• Responsible for reviewing criteria on denial letters
• Responsible to handle multiple audits and able to prioritize workflow

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires an active California LVN license
• Requires at least 3 years of prior relevant experience in auditing of claims, credentialing, or re-credentialing
• Requires experience in auditing of utilization management or prior out-patient authorization review
• Desired knowledge of accreditation entities and their requirements
• Required ability to work independently
• Required excellent verbal and written communication skill and interpersonal skills
• Desired Computer ease & literacy with Word, Excel, Power Point Skills

Pay Range:

The pay range for this role is: $ 71280.00 to $ 99770.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.