Delegation Oversight Specialist Nurse - Hybrid (PA/NJ/DE)

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

This Delegation Oversight Specialist – RN role involves oversight of delegated activities to ensure compliance with NCQA accreditation standards, CMS, and state regulatory requirements. Ideal candidate will be an excellent communicator (written and verbal) who is detail oriented, organized, able to read and interpret regulations and able to meet tight deadlines while handling multiple audits.

Responsibilities:

• Coordinates, conducts and documents required pre-delegation assessments and annual NCQA assessments as necessary to comply with applicable state, federal and accreditation requirements,
• Conducts necessary monitoring and auditing work to ensure vendors comply with  state, federal, NCQA and other applicable requirements.
• Review reports from Delegated Entities.
• Develops corrective action plans when deficiencies are identified and document follow-up to completion.
• Present delegate’s performance to respective committees, including the preparation of documents for committee oversight of delegated functions.
• Review implementation of new or changed regulatory requirements to help ensure adequacy of controls of oversight activities
• Provide guidance of new or changed regulatory requirements and implementation of processes.
• Analyzes and interprets existing and proposed legislation and regulations and determines their effects on delegation oversight process.
• Conduct risk assessments to identify required audit areas and audit frequency.
• Assist in developing audit tools of oversight activities.
• Work collaboratively with Delegation Manager/Director to develop, establish and maintain departmental processes and procedures.  
• Performs other duties as required.

Qualifications:

• Active, unrestricted RN license
• Three years of auditing experience in a managed care, health plan, regulatory compliance, or delegation oversight environment utilizing NCQA, CMS requirements, and state and federal regulatory requirements preferred.
• Experience in delegation oversight processes across multiple delegated functions (e.g., utilization management, case management, network management, appeals and grievances, and other delegated health plan operations).
• Demonstrated knowledge of applicable regulatory, accreditation, and contractual requirements, including NCQA standards and CMS regulations, preferred.
• Intermediate proficiency in the use of Office365 (e.g. Word, Excel) required.