Delegation Oversight Auditor

Company: Bright Health
Location: Diamond Bar
Posted on: September 17, 2022

Job Description:

SCOPE OF ROLE
Under the general direction of the Manager of Delegation Oversight, the Delegation Oversight Auditor will participate in utilization management audits of the delegated provider groups. Serve as liaison to delegated IPA and subcontracted providers to ensure compliance of delegated functions and Health Plan standards. Problem-solve issues for internal and external stakeholders. Provide guidance on regulatory requirements. Assist with regulatory audit(s) preparation and coordination
ROLE RESPONSIBILITIES
TheDelegation Oversight Auditor description is intended to point out major responsibilitieswithin the role, but it is not limited to these items.

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• Oversight of clinical operations for the delegated IPA and subcontracted providers
  
• Timely follow-up and completion of necessary follow-up action that may include, educational letters, training, corrective action plan (CAP), concurrent review, and any additional audits
  
• Coordination and scheduling of various audits
  
• Serve as a regulatory resource person and trainer to IPA's staff regarding regulatory requirements, health plan standards and processes
  
• Maintain efficient and accurate records.
  
• Actively participation in both internal & external meetings and webinar training sessions.
  
• Tracking & collection of incoming required UM documents.
  
• Ensure timeliness of required Health Plan reports.
  
• Identify patterns, deficiencies, and trend audit findings.
  
• Coordinates and gathers documentation to respond to audits conducted either internally or externally
  
• Prepare delegate compliance report and tracking logs
  
• Assist with the policy and procedures updates, as necessary.
  
• Other duties as assigned, as needed
  
• The position will also develop reports regarding audits, analyze, track and
  
  EDUCATION, TRAINING, ANDPROFESSIONAL EXPERIENCE
  
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  • Current and unrestricted LicensedPracticalNursing or Licensed Vocational Nurse certificate from an accredited Nursing Programor equivalent experience in UM auditing.
    
  • Minimum 5 years' experience in Medical Management (Utilization Management, appeals and grievances, Concurrent Review).
    
  • Driver's license, auto insurance, and safe driving history
    
  • Preferred: Over 2 years of experience in health plan or healthcare auditing, compliance and/or operations.
    
  • Awareness and experience with HIPAA requirements for healthcare communications preferred
    
  • Familiarity with developing and implementing auditing and monitoring processes across systems, internal areas and FDRs.
    
    PROFESSIONAL COMPETENCIES
    
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    • Prioritizes and plans work activities; uses time efficiently andcanmulti-task.
      
    • Excellent communication skills, both oral and written
      
    • Approaches challenges calmly and objectively to identify the best solution
      
    • Capable communicator that can interact with others at multiple levels within the organization, customers and providers
      
    • Able to type 30 wpm
      
    • Strong operational mindset and uses data to draw insights
      
    • Thrives on driving results in a collaborative environment
      
      LICENSURES ANDCERTIFICATIONS
      
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      • Current Unrestricted LicensedPracticalNursing or Licensed Vocational Nurse certificate from an accredited Nursing Program in California; or equivalent combination of education and experience.
        
        WORK ENVIRONMENT
        
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        • Most work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
          
        • Travel, up to 10% of the time may be required.
          

Keywords: Bright Health, Diamond Bar , Delegation Oversight Auditor, Accounting, Auditing , Diamond Bar, California