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As part of Molina’s response to the COVID-19 pandemic, unless otherwise prohibited by law, new hires with a start date of November 1, 2021 or later will be required to be fully vaccinated.

Delegation Oversight UM Audit Nurse (Work At Home)

Molina Healthcare Fontana, California Job ID 2011299
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Job Description

The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team.

This position is currently remote/work-from-home, but will eventually require onsite visits at the offices of our delegates (in San Diego, San Bernardino, Riverside, Orange, Los Angeles, and Sacramento), as well as some in-office days in our Long Beach HQ.  

Job Summary
Responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including delegation standards and requirements contained in the delegation agreement.

Knowledge/Skills/Abilities
The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. This includes, but is not limited to:
• Coordinates, conducts, and documents pre-delegation and annual assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
• Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement as needed.
• Works with Delegation Oversight Analyst on monitoring of performance reports from delegated entities.
• Develops corrective action plans when deficiencies are identified, and documents follow up to completion.
• Assists with meetings of the Delegation Oversight Committee.
• Works with the Delegation Oversight Manager to develop and maintain delegation assessment tools, policies, and reporting templates.
• Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees.
• Participates as needed in Joint Operation Committees (JOC's) for delegated groups.
• Assists in preparation of documents for CMS, State Medicaid, NCQA, and/or other regulatory audits as needed.

REQUIRED EDUCATION: 
Completion of an accredited Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), or Registered Nurse (RN) Program.

REQUIRED EXPERIENCE: 
Minimum two years Utilization Review experience. 
Knowledge of audit processes and applicable state and federal regulations.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
Active, unrestricted California State Licensed Vocational Nurse or Registered Nurse License in good standing.

PREFERRED EDUCATION: 
Completion of an accredited Registered Nurse (RN) Program or a Bachelor's Degree in Nursing.

PREFERRED EXPERIENCE: 
Three year NCQA, CMS, and/or state Medicaid UM auditing experience.
Three year's experience in delegation oversight process and working knowledge of state and federal regulations.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION: 
Certified Clinical Coder, Certified Medical Audit Specialists (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM)  Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

PHYSICAL DEMANDS:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.



To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
 

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 11/11/2021

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