Position Title: Clinical Compliance Nurse (Part-Time)

Department: Medical Management

Level: Non-Supervisory

Reports To: Director of Medical Management

Position's Access to Private Health Information (PHI): Position requires “read and write” access to member authorizations, “read only” access to claims and eligibility.

Job Classification: Non-Exempt

Job Type: Part-Time

Pay Rate: $42.20 - $51.71/hr. Salary is based on qualifications and experience.

Position Summary:

Supports and facilitates the delegation processes across product lines by assisting with delegation oversight audits with the health plans. Ensuring policies/procedures, documentation and reports are in compliance with regulatory and applicable accreditation guidelines, and are meeting required standards.

Essential Job Functions:

· Schedule audit and prepare documents for individual health plan UM audits. This would include file selection and assembling of all the documents for the audit.

· Review and update on annual basis Medical Management Program, Policies and Procedures to comply with changes in NCQA and regulatory requirements to meet annual health plan audit requirements

· Participate in health plan CMS audits, query the databases, completing CMS universe templates, submission of templates, as applicable

· Respond to corrective action plans timely, as applicable

· Completion and submission of ICE semi-annual health plan specific UM reports

· Completion and submission of ad hoc health plan report requests-NCQA denial, DMHC denials for specified timeframe, CMS validation submission reports

· Other duties as assigned: Claims Review

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Position Qualifications and Requirements:

Experience/Specialized Skills:

· Prior experience in health plan, medical group delegation, NCQA surveys or auditing experience.

· Utilizes strong verbal and written communication skills.

· Proficient with computer, Microsoft windows environment.

Education/Course(s)/Training:

· Registered Nurse

Licensure/Certification: Registered Nurse, active California License

Location: Mira Mesa, San Diego

Date Posted: 05.20.2024

To apply for this position, complete the employment application following the link below and submit it to jobs@scpmcs.org

Job Type: Part-time

Pay: $42.20 - $51.71 per hour

Expected hours: No more than 20 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Application Question(s):

• How much knowledge of HCFA, Medi-Cal, and HMO claims payment regulations do you have?
• What is your salary expectation?

Education:

• Associate (Required)

Experience:

• Health Plan/Medical Group Delegation: 1 year (Required)
• NCQA Surveys or Auditing: 1 year (Preferred)

Ability to Relocate:

• San Diego, CA 92121: Relocate before starting work (Required)

Work Location: Hybrid remote in San Diego, CA 92121