Delegation Operations Nurse Auditor
3 weeks ago
Your Role
The Delegation Oversight Utilization Management team is responsible for the organization, tracking and data entry of IPA Utilization Management audits, issues, complaints and monitoring. Identifies root cause of the problem and maintains monthly reporting that track and compare patters of delegated entities. The Delegation Operations Nurse Auditor-LVN-Experienced will report to the Manager of UMDO. In this role you will be assist in maintaining continuous quality improvement in the Utilization Management Delegation Oversight Clinical Audit ensuring that departmental and organizational goals are accomplished through oversight and facilitating Utilization Management compliance of the Plan Partners.
Your Work
In this role, you will:
- Be responsible for overseeing policy and procedure review and completing limited and less complex full desk or onsite Pre-delegation, Annual or follow-up audits /assessments of delegated entities, including vendors, in support of the regulatory and NCQA requirements.
- Act as the auditor in charge on small and less complex audits, with supervision, of Sr. management and other delegated non-clinical areas through to corrective action plan oversight.
- Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
- Educate the delegated entities and vendors on area of expertise including but not limited to claims payment management, credentialing management, financial solvency, and system controls.
- Collaborate on regulatory audits, findings responses or enforcements by regulatory agencies.
- Responsible to write Corrective Action Plans and comprehensive summaries
- Knowledge of DMHC, DHCS, CMS, Title 22 CCR, Title 28, Title 42, and Medi-Cal, Medicare processing guidelines
- Ability to effectively communicate with internal and external associates
- Responsible for reviewing criteria on denial letters
- Responsible to handle multiple audits and able to prioritize workflow
Your Knowledge and Experience
- Requires a bachelor's degree or equivalent experience
- Requires an active California LVN license
- Requires at least 3 years of prior relevant experience in auditing of claims, credentialing, or re-credentialing
- Requires experience in auditing of utilization management or prior out-patient authorization review
- Desired knowledge of accreditation entities and their requirements
- Required ability to work independently
- Required excellent verbal and written communication skill and interpersonal skills
- Desired Computer ease & literacy with Word, Excel, Power Point Skills
Pay Range:
The pay range for this role is: $ 71280.00 to $ 99770.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
#LI-RU1
-
Operating Room
3 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Operating Room RNs for an immediate travel nurse opening in Springfield, MO. The right RN should have 1-2 years recent acute care experience as a circulating nurse, and/or scrub nurse, and potentially RN first...
-
Operating Room
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Operating Room RNs for an immediate travel nurse opening in Albany, NY. The right RN should have 1-2 years recent acute care experience as a circulating nurse, and/or scrub nurse, and potentially RN first...
-
Intensive Care Unit
3 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Intensive Care Unit RNs for an immediate travel nurse opening in Concord Township, OH. The right nurse should have 1-2 years recent acute care experience. Read below for more requirements. As an ICU Travel Nurse,...
-
Intensive Care Unit
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Intensive Care Unit RNs for an immediate travel nurse opening in Springfield, MO. The right nurse should have 1-2 years recent acute care experience. Read below for more requirements. As an ICU Travel Nurse,...
-
Intensive Care Unit
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Intensive Care Unit RNs for an immediate travel nurse opening in Herrin, IL. The right nurse should have 1-2 years recent acute care experience. Read below for more requirements. As an ICU Travel Nurse, you'll...
-
Intensive Care Unit
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Intensive Care Unit RNs for an immediate travel nurse opening in Rochester, NY. The right nurse should have 1-2 years recent acute care experience. Read below for more requirements. As an ICU Travel Nurse,...
-
Intensive Care Unit
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Intensive Care Unit RNs for an immediate travel nurse opening in Newark, NY. The right nurse should have 1-2 years recent acute care experience. Read below for more requirements. As an ICU Travel Nurse, you'll...
-
Clinical Services Coordinator, Advanced
1 week ago
Long Beach, California, Los Angeles County, CA, United States Blue Shield of California Full timeYour Role The Medical Care Solutions Clinical Service Intake team responsible for timely and accurate processing of Treatment Authorization Request. The Clinical Services Coordinator will report to the Supervisor of Clinical Services Intake. In this role you will be for supporting clinical staff day to day operations for Promise lines of business. Your...
-
Operating Engineer
3 weeks ago
Venice, California, 90291, Los Angeles County, CA, United States *US AMR-Jones Lang LaSalle Americas, Inc. Full timeWhat this job involves:The Operating Engineer has wide ranging responsibilities for the electrical and mechanical systems at the assigned buildings; including but not limited to the following:Maintain and update current CMMS information for all building operating systems. Maintain the various building systems, including but not limited to HVAC, Electrical,...
-
Pediatric OR
1 week ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Pediatric Operating Room RNs for an immediate travel nurse opening in Seattle, WA. The right RN will have at least 1-2 years of recent acute care experience. Read below for more requirements: Pediatric Operating...
-
Emergency Room
3 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Emergency Room RNs for an immediate travel nurse opening in Alpine, TX. The right RN should have 1-2 years recent acute care experience. Read below for more requirements. As an ER Travel Nurse, you will work with...
-
Emergency Room
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Emergency Room RNs for an immediate travel nurse opening in Urbana, IL. The right RN should have 1-2 years recent acute care experience. Read below for more requirements. As an ER Travel Nurse, you will work with...
-
Emergency Room
4 days ago
Mission Hills, California, 91346, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Emergency Room RNs for an immediate travel nurse opening in Mission Hills, CA. The right RN should have 1-2 years recent acute care experience. Read below for more requirements. As an ER Travel Nurse, you will...
-
Emergency Room
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Pediatric Emergency Room RNs for an immediate travel nurse opening in Tacoma, WA. The right RN will have at least 1-2 years of recent acute care experience. Read below for more requirements: As a Pediatric ER...
-
Cardiovascular Intensive Care Unit
2 weeks ago
Los Angeles, California, 90079, Los Angeles County, CA, United States Travel Nurse Across America Full timePut another $10,000 in your pocket when you take 5 assignments. Up to 15 weeks of vacation. For real.Apply for more details!We're looking for Cardiovascular Intensive Care Unit RNs for an immediate travel nurse opening in Wilkes Barre, PA. The right RN should have 1-2 years' recent acute care experience. Read below for more requirements. As a CVICU...
-
Outpatient Registered Nurse
2 weeks ago
Lancaster, California, 93539, Los Angeles County, CA, United States Fresenius Medical Care Full timePOSITION FEATURES:This is a full-time opening at our clinic in LancasterWeekly schedule after training: Tues/Thur/Sat, 10a-11p-closerRN's with no dialysis experience will have a training schedule for approx 3 months, 5 days per weekPURPOSE AND SCOPE: The professional registered nurse Outpatient RN CAP 1 is an entry level designation into the Clinical...
-
Outpatient Registered Nurse
7 days ago
Lancaster, California, 93539, Los Angeles County, CA, United States Fresenius Medical Care Full timePOSITION FEATURES:This is a full-time opening at our clinic in LancasterWeekly schedule after training: Tues/Thur/Sat, 10a-11p-closerRN's with no dialysis experience will have a training schedule for approx 3 months, 5 days per weekPURPOSE AND SCOPE: The professional registered nurse Outpatient RN CAP 1 is an entry level designation into the Clinical...
-
Registered Nurse Med Surg
2 days ago
Culver City, California, 90232, Los Angeles County, CA, United States Alta Hospitals Full timeThe Charge Nurse oversees clinical functions related to the delivery of patient care, the quality of nursing practice and the standards of care for the assigned shift. Directs patient care activities by assigning staff and functions on the unit based on the Charge RN’s assessment of patient needs and the relative skills and abilities of staff, while...
-
Nursing Department Manager, Operating Room FT
3 weeks ago
Los Angeles, California, 90071, Los Angeles County, CA, United States Kaiser Full timeJob Summary:Manages the delivery of nursing services and safe patient care within assigned department and across the continuum of care. Manages the delivery of services that add value and are integrated with nursing standards of practice, service priorities and performance/outcome measures, as well as with strategic, business and organizational...
-
Nursing Department Manager, Operating Room FT
2 weeks ago
Los Angeles, California, 90071, Los Angeles County, CA, United States Kaiser Full timeJob Summary:Manages the delivery of nursing services and safe patient care within assigned department and across the continuum of care. Manages the delivery of services that add value and are integrated with nursing standards of practice, service priorities and performance/outcome measures, as well as with strategic, business and organizational...
