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Delegation Oversight Specialist - RN

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Independence Blue Cross

1mo ago

  • Job
    Full-time
    Mid Level
  • Healthcare
    Legal
  • Philadelphia

AI generated summary

  • You need an active RN license, experience in Utilization Review or Case Management, three years of auditing with NCQA guidelines, and intermediate Office365 skills.
  • You will assess and monitor vendor compliance, analyze regulations, develop corrective action plans, present performance reports, and support oversight processes.

Requirements

  • Active, unrestricted RN license
  • Experience with either Utilization Review and/or Case Management
  • Three years auditing experience using NCQA guidelines preferred
  • Experience in delegation oversight process and working knowledge of Part C Organization Determination regulations and NCQA Health Plan standards preferred
  • Intermediate proficiency in the use of Office365 (e.g. Word, Excel) required

Responsibilities

  • Coordinates, conducts and documents required pre-delegation assessments and annual NCQA assessments as necessary to comply with applicable state, federal and accreditation requirements,
  • Conducts necessary monitoring and auditing work to ensure vendors comply with state, federal, NCQA and other applicable requirements.
  • Review reports from Delegated Entities.
  • Develops corrective action plans when deficiencies are identified and document follow-up to completion.
  • Present delegate’s performance to respective committees, including the preparation of documents for committee oversight of delegated functions.
  • Review implementation of new or changed regulatory requirements to help ensure adequacy of controls of oversight activities
  • Provide guidance of new or changed regulatory requirements and implementation of processes.
  • Analyzes and interprets existing and proposed legislation and regulations and determines their effects on delegation oversight process.
  • Conduct risk assessments to identify required audit areas and audit frequency.
  • Assist in developing audit tools of oversight activities.
  • Work collaboratively with Delegation Manager/Director to develop, establish and maintain departmental processes and procedures.
  • Performs other duties as required.

FAQs

What is the primary role of a Delegation Oversight Specialist - RN?

The primary role of a Delegation Oversight Specialist - RN involves overseeing delegated activities to ensure compliance with NCQA accreditation standards, CMS, and state regulatory requirements.

What are the key responsibilities of this position?

Key responsibilities include coordinating and conducting pre-delegation and annual NCQA assessments, monitoring vendor compliance, reviewing Delegated Entity reports, developing corrective action plans, presenting delegate performance to committees, and analyzing regulatory changes.

What qualifications are required for this role?

Candidates must have an active, unrestricted RN license, experience in Utilization Review and/or Case Management, and three years of auditing experience using NCQA guidelines. Knowledge of delegation oversight processes and Part C regulations is preferred.

Is experience with Office365 necessary for this position?

Yes, intermediate proficiency in the use of Office365 (e.g., Word and Excel) is required for this role.

How does the Delegation Oversight Specialist contribute to compliance and risk assessment?

The specialist conducts risk assessments to identify required audit areas, analyzes existing and proposed regulations, and helps to ensure the adequacy of controls in oversight activities based on regulatory changes.

Will the specialist work alone or in collaboration with others?

The Delegation Oversight Specialist will work collaboratively with the Delegation Manager/Director to develop, establish, and maintain departmental processes and procedures.

Are there any additional duties expected from the Delegation Oversight Specialist?

Yes, the position may require the performance of other duties as necessary in addition to the outlined responsibilities.

What type of communication skills are necessary for this role?

Excellent written and verbal communication skills are essential for effectively presenting data, developing documents, and interacting with various stakeholders.

What is the significance of conducting audits for this position?

Audits are crucial for ensuring that vendors comply with state, federal, and accreditation requirements, which helps in maintaining quality and accountability within the delegated activities.

Independence Blue Cross

Finance
Industry
5001-10,000
Employees
1938
Founded Year

Mission & Purpose

Independence Blue Cross is the leading health insurance organization in southeastern Pennsylvania. For 85 years, we have been enhancing the health and well-being of the people and communities we serve. We deliver innovative and competitively priced health care products and services; pioneer new ways to reward doctors, hospitals, and other health care professionals for coordinated, quality care; and support programs and events that promote wellness.