The JobPerforms and provides oversight to the Managed Care Plan's (MCP) Department of Health Care Services (DHCS) auditing team responsible for conducting and overseeing both initial and subsequent reviews of Primary Care Provider (PCP) sites. These reviews include a Facility Site Review (FSR) and a Medical Record Review (MRR), utilizing the tools and standards set by DHCS. The site review process is an integral part of the MCPs quality improvement programs, focusing on each PCP site's capacity to provide safe and effective clinical services.
Support monthly audit assignments by completing all required audit work within the established timelines and ensure the documentation is thorough and aligned with regulatory and compliance requirements.
**The ideal RN candidate will be located in the Los Angeles area or Long Beach area, since most audits will take place in the LA region and the role would need to flex into Inland Empire/San Diego when required**You Will- Conducts detailed review, analysis, and interpretation of DHCS All Plan Letters (APL) and works with designated DHCS-CMT and manager to deploy.
- Using critical thinking skills, identify impactful areas for regulatory compliance to develop an effective implementation communication plan.
- Facilitates the auditing of SCAN contracted and collaborative PCP offices that see Medi-Medi members, in accordance with CMS and DHCS and contractual requirements to ensure compliance. Provides training on all aspects of auditing and post audit documentation, providing feedback and identifies opportunities for improvement.
- Conducts closing meetings with audited providers to give them a preliminary overview of completed compliance audits Assists providers in achieving and maintaining compliance with SCAN, Federal, State and NCQA requirements and guidelines including the development and implementation of corrective action plans (CAP), monitoring CAP activities and providing education and tools Responds to audited providers as disagreements with audit findings arise Analyzes submitted reports from providers, including the request for corrections from providers as needed Communicates regulation interpretations and explains their application, provides supplemental information if needed Conducts detailed review, analysis, and interpretation of legislative, statutory, regulatory, and contract language.
- Conducts all aspects of annual oversight projects, individual correspondence; coordination of projects with internal SCAN staff and departments; monitoring and reporting delegated compliance; tracking, trending and reporting upon project status; coordinating with Compliance regarding report submissions and regulatory updates Uses critical thinking skills and identifies impactful areas for provider data requirements to develop an effective implementation and communication plans.
- Functions as the service delivery compliance subject matter expert by representing the Delegation Oversight Unit (DOU) in interdepartmental meetings and partnering with Compliance to develop and implement SCAN policy regarding NCQA, DHCS, CMS and/or other regulatory revisions Utilizes department desktop procedures, workflows, job aids and training material Escalates longstanding issues of non-compliance in accordance with P&P's Identifies barriers and brings to the attention of the supervisor/manager
- Educates providers on such topics as compliant delegated claims processing and the denial of claims with member liability in accordance with CMS, local state and SCAN contractual requirements Maintains the member's right to privacy and protect SCAN operations by keeping information confidential
- Reviews letters from internal and delegated administrators, Compliance Program processes, or data submissions for accuracy and compliance with CMS and contractual requirements, and recommends delegation status based on results Adheres to all quality, compliance and regulatory standards to achieve SCAN outcomes
- This role requires driving in assigned territory and have the ability flex to other areas as assigned.
- Must have a valid driver's license, automobile insurance and reliable transportation
- We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
- Actively support the achievement of SCAN's Vision and Goals.
- Other duties as assigned.
Your Qualifications- Registered Nurse License (RN) required (current and active California license in good standing).
- 2+ years Clinical experience including but not limited to ER/Acute Care nursing required. IPA, Medical Group experience preferred.
- Associate's Degree in Nursing, Bachelor's Degree preferred.
- DHCS-CSR (certified site reviewer) strongly preferred; or ability to become certified within 1 year of taking position (after successful completion of training).
- Prior auditing experience preferred.
- Must be able to work independently as well as in a team environment.
- Handles basic issues and problems, and refers more complex issues to higher-level staff.
- Possesses beginning to working knowledge of subject matter.
- Technical expertise - Basic technical skills for functional area
- Problem Solving - Basic problem-solving skills
- Communication - Good communication and interpersonal skills
- Must have analytical, critical thinking, problem solving, and decision making skills
- Strong attention to detail and organizational skills.
- Ability to prioritize multiple and competing tasks in a fast paced environment.
- Proficient in MS Office and data entry.
- This role requires driving in assigned territory
What's in it for you?- Base Pay Range: $38.61 to $55.86 per hour
- Work Mode: Remote/Field (This role requires driving in assigned territory)
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
- Excellent 401(k) Retirement Saving Plan with employer match
- Robust employee recognition program
- Tuition reimbursement
- An opportunity to become part of a team that makes a difference to our members and our community every day!
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
