Description

This position is responsible for leading, coordinating and participating in clinical delegation oversight audits of client's vendors, service providers, medical groups and/or delegated subcontracted providers reviewing adherence to regulatory and contractual requirements. The position also develops audit tools based on state and federal regulations, conducts the reviews in accordance with accreditation standards and clinical guidelines . Creates reports regarding audits, and analyzes, tracks and trends audit findings. Develops and monitors corrective actions and provides feedback to practitioners on performance. May support in drafting amendments to agreements.

Job Responsibilities:
• Provides ongoing monitoring and education to Subcontractors staff related to Clinical and behavioral health requirements, performs Clinical and Mental Health onsite audits, including scheduling and educating the subcontractors on purpose and process of oversight, oversees clinical processes for participating and prospective subcontractors related to medical and behavioral health
• Participate in development, implementation and management of process and system to monitor and evaluate Enterprise delegated activities to subcontractors, Medical groups, IPAs and vendors for Commercial, Exchange, Medicare and Medicaid products.
• Provide input and perform maintenance of Enterprise pre-delegated and delegated oversight documentation (policies, procedures, audit tools, guidelines, reporting formats, communication materials and scheduling) consistent with the intent of regulatory/accreditation requirements for the enterprise.
• Schedule and perform timely pre-delegation assessments (documentation and onsite) of proposed delegated groups according to established Enterprise policies to determine delegates compliance with regulatory/accreditation standards, ability to perform proposed delegated functions and ability to meet quality and service goals.
• Prepare timely pre-delegation assessment report, summary and recommendation and disseminate to management, internal areas and committees for analysis to the appropriate areas.
• Schedule and perform annual and periodic audits (documentation and onsite) of delegated groups according to established Enterprise policies to ensure continued compliance with regulatory/accreditation requirements and standards while staying within budget requirements.
• Make initial decision and recommendation if subcontractors processes and operations are compliant with multiple Health Plans, State and federal regulatory requirements and accreditation standards including staffing, policy and procedures, infrastructure, Certificate/Licensures, insurance, system and facilities.
• Verify receipt of delegate reporting and perform necessary follow-up to ensure receipt of reporting. Monitor and review reporting to ensure accuracy, summarize compliance with established goals and disseminate to management, internal areas and committee for analysis, identification of areas for improvement, action plans and follow-up.
• Prepare timely delegation audit report, summary and recommendation and disseminate to management, internal areas and committees for analysis, identification of areas for improvement, action plans and follow up.
• Determining and prioritizing critical issues that should be escalated to contract owner, executive management and compliance to help mitigate risks for sanctions, liquidated damages or harm to members.
• Participate on multiple state DOC and QI committees with recommendations and evaluation of subcontractors performance with accreditation and regulatory compliance, pre-delegation evaluations and audits, implementing project plans, accuracy and timely of reports, and corrective action plan.
• Participate on Subcontractors joint operation meeting with contract owner and multiple health plan core operational areas to address ongoing monitoring and operational issuers.
• Perform project management role to consult and evaluate with outside agencies and/or subcontractors executive management for implementing new networks/products and/or new types of subcontracting for health plan operations that include outsourcing or delegating functions to different types subcontractors
• Prepare and participate on multiple state audits i.e. internal audits, accreditation (URAC/NCQA), Department of Insurance, Medicaid, Medicare and Exchange
• Participate in Enterprise contract negotiations to include review of contracting language, additions, deletions, etc.

Act as an advisor/subject matter expert on standards/regulations.
• Designs and provides education programs to Subcontractors, annually. Education may include appropriate clinical and mental health referrals, discussion of different levels of care, and various clinical and mental health topics such as coordination of care, disease and treatment.
• Conducts an annual joint meeting to medical groups with provider network consultants to educate about services and facilities available and problem solve clinical issues.
• Reviews and approves the annual clinical UM/CM/QI/DM and Care Coordination plans submitted by contracted management firms affiliated with the HMOI medical groups. Reviews and approves medical UM Plans for assigned medical groups/IPAs.
• Assists providers and FSUs in resolving complicated issues related to claims or referrals.
• Develops written policies and procedures related to Clinical and Behavioral Health, including UM/CM/QI/DM/CC Plan documents.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Monitor vendor/delegate compliance with state and federal laws. Assist with implementation of new laws contract arrangements. Develop and enforce corrective action plans if delegates are non-compliant

Required Job Qualifications:
• Registered Nurse (RN), unrestricted license to practice in state.
• 3 years managed care experience or health plan operations experience
• Experience developing and analyzing reports
• Experience in performing delegation oversight and monitoring multiple delegated functions, state and products
• Experience interpreting and implementing accreditation standards (NCQA and URAC).
• Experience to interpret and implement state and federal health insurance regulations.
• Organizational skills
• Verbal and written communications skills to include delivering presentations to committees and acting as company representative to subcontractor management (Vendors and Delegates)
• PC experience to include Microsoft Office suite of applications (Word, Excel)
• Able and willing to travel, including overnight stays (approximately 30% overnight travel).

Preferred Job Qualifications:
• Bachelor degree in Nursing, Health Care Administration or health care field.
• Experience in auditing accreditation standards and state and federal regulations
• Medicaid or Medicare experience
• Presentation application experience (such as PowerPoint) and database experience.
• Project management experience including leading projects.
• Experience in creating and writing processes, policy and procedures.