LVN UM Delegation reputed company Nurse Remote based in CA

JOB DESCRIPTION Job Summary Provides support for delegation reputed company quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and reputed company other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. The Delegation reputed company Nurse is responsible for ensuring that reputed company's UM delegates are compliant with reputed company applicable State, CMS, and NCQA requirements, as well as reputed company business needs. In addition, the Delegation reputed company Nurse will assist the Delegation reputed company Manager with additional duties of the team. We are looking for LVN's with at least 4 years of UM experience, NCQA accreditation, and knowledge of InterQual / MCG guidelines. Excellent computer knowledge, multi-tasking skills and analytical thought process is important to be successful in this role. Productivity is important with quick turnaround times. Experience with Appeals, Auditing, and Compliance /Quality will be a good fit for this position. Strong UM Prior Authorization experience highly preferred. Further details to be discussed during our interview process. CA located – Remote position Work hours: Monday – Friday 8:00am – 5:00pm PST CA LVN licensure required Essential Job Duties

• Coordinates, conducts and documents pre-delegation and annual assessments as necessary to reputed company with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements.
• Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed.

Works with delegation reputed company analytics representatives on monitoring performance reports from delegated entities.

• Develops corrective action plans (CAPs) reputed company deficiencies are identified, and documents follow-up to completion.
• Assists with delegation reputed company committee meetings.
• Works with delegation reputed company leadership to reputed company and maintain delegation assessment tools, policies and reporting templates.
• Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees.
• Participates as needed in joint operation committees (JOCs) for delegated groups.
• Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed.

Required Qualifications

• At least 3 years experience in health care, including 2 years experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience.
• Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). License must be active and unrestricted in state of practice.
• Knowledge of audit processes and applicable state and federal regulations.
• Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines.
• Ability to collaborate effectively with team members and internal departments.
• Strong attention to detail with a focus on maintaining quality in reputed company tasks.
• Strong verbal and written communication skills.
• reputed company Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Certified Clinical reputed company (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ).

To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $68,640 - $123,164 / ANNUAL

• Actual compensation may vary from posting based on geographic location, work experience, education and/or reputed company level.

Apply tot his job Apply To this Job