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Clinical Delegation Oversight Specialist
2 months ago
At The Health Plan of West Virginia Inc, we are seeking a highly skilled Clinical Delegation Oversight Coordinator to join our team. This role is responsible for ensuring that delegated contracts to perform clinical functions in utilization management and population health management are in compliance with all regulatory and accreditation requirements.
Key Responsibilities:- Provide oversight of all current clinical delegates and vendors through regular auditing and monitoring.
- Assist in continuous quality improvement activities related to delegated functions.
- Collaborate with Quality Improvement, Compliance, and Operations departments to stay up-to-date on current legislation, regulations, and accreditation changes.
- Prepare for internal audits and identify opportunities for improvement with internal staff and delegates.
- Develop and conduct ongoing monitoring activities, including file reviews, letters, timeliness, and supplemental reports.
- Provide training, education, and remediation to delegated entities as needed.
- Monitor delegation agreements and review semiannual reporting, performance monitoring, and member and clinical data sharing.
- Perform pre-delegation oversight activities as outlined by NCQA standards and guidelines.
- Review the UM and PHM program against NCQA standards and guidelines and prepare documents, policies, and procedures for survey and audit readiness.
- Act as a liaison between the Plan and delegates, vendors, and FDRs.
Requirements:
- Registered Nurse, licensed practical nurse, or health-related degree with at least 3-5 years of experience in managed care settings in quality improvement, case management, or utilization management.
- Project management experience.
- Working knowledge of NCQA standards and guidelines.
- Working knowledge of Medicare Parts C & D Compliance.
- Excellent interpersonal and communication skills.
- Proficient in Microsoft Office Suite products.
Desired Qualifications:
- Clinical delegation oversight project management experience.
- Auditing experience.
Why Join Our Team:
The Health Plan of West Virginia Inc is a leading healthcare organization dedicated to providing high-quality services to our members. As a Clinical Delegation Oversight Coordinator, you will have the opportunity to work with a talented team of professionals who share your passion for delivering exceptional care. We offer a dynamic and supportive work environment, competitive compensation, and opportunities for professional growth and development.
