Compliance Oversight Nurse

7 days ago


Riverside, California, United States UHS Full time

About the Job:

The Compliance Oversight Nurse plays a crucial role in ensuring compliance with health plan requirements at Universal Health Services (UHS). As a key member of our team, you will be responsible for overseeing delegated and compliance operations, maintaining efficient records, and identifying patterns, deficiencies, and trend audit findings.

Key Responsibilities:

  • Oversight of delegated and compliance operations with health plans.
  • 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 staff regarding regulatory requirements, health plan standards, and processes.
  • Maintain efficient and accurate records.
  • Actively participate 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.
  • Review denial letters for clinical criteria and appropriate language.
  • Coordinates and gathers documentation to respond to audits conducted either internally or externally.
  • Prepare delegate compliance reports and tracking logs.
  • Assist with the policy and procedures updates, as necessary.
  • Support the Delegation Oversight Analyst in the development and validation of reports regarding audits, including analyzing, tracking, and monitoring compliance with regulatory and health plan requirements.

Requirements:

  • An associate degree is required, while a bachelor's degree is preferred.
  • A minimum of 3 years of experience in medical management, utilization management, appeals and grievances, and/or concurrent review.
  • Over 2 years of experience in a health plan or healthcare auditing, compliance, and/or operations.
  • Awareness and experience with HIPAA requirements for healthcare communications are preferred.
  • Familiarity with developing and implementing auditing and monitoring processes across systems, internal areas, and first-tier downstream-related entities (FDRs).
  • Knowledge of Compliance Program principles, including analyzing risk assessments, performing audits, contracting, creating reports, educating, and following up with business areas to ensure processes exist to demonstrate compliance with Federal and State requirements.

Benefits:

  • A competitive salary: $83,000 - $108,000 per year, depending on experience.
  • Challenging and rewarding work environment.
  • Growth and Development Opportunities within UHS and its subsidiaries.
  • Benefits package, including medical, dental, and vision insurance.

About UHS:

Universal Health Services (UHS) is one of the nation's largest and most respected providers of hospital and healthcare services. We operate acute care hospitals, behavioral health facilities, outpatient facilities, and ambulatory care access points throughout the United States, Washington D.C., Puerto Rico, and the United Kingdom. Our commitment to providing high-quality patient care and excellent service has earned us recognition as one of the World's Most Admired Companies by Fortune.



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