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Position Description: Occasional travel to multiple sites and different locations. Direct Hire Position POSITION SUMMARY Under the general direction of the Senior Manager, Delegation Oversight, the RN_I Auditor, Delegation Oversight, leads, coordinates and participates in all delegation oversight audits of Gold Coast Health Plan"s vendors, service providers and delegated subcontracted providers according to regulatory and contractual requirements. In support of the Senior Manager, Delegation Oversight, the RN_I Auditor, Delegation Oversight, assists in the liaison role between the subcontracted providers in the delegation oversight process. The position will also lead the delegation audit process, develop reports regarding audits, and analyze, track and trend audit findings. A second core function of the position is to support the Gold Coast Health Plan"s compliance department. The focus in this area is to convey information to and problem-solve issues for internal and external stakeholders. Provide guidance on regulatory requirements and reporting. Assist with regulatory audit(s) preparation and coordination. ESSENTIAL FUNCTIONS Reasonable Accommodations Statement To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions. Essential Functions Statement(s) • Class Characteristics: • The incumbent performs a variety of administrative duties that require a degree of analytical, organizational and technical skills and exercises a level of discretion and judgment appropriate for the scope of the position. While the supervision of others is minimal at this time, this is a management level position. • Major Duties and Responsibilities: • Lead/Coordinate the scheduling of delegation oversight audits. • Provide administrative support to Health Plan staff in the acquisition and distribution of files for audit. • Participate in the audit process. Assist Health Plan staff in the development and routing of the audit findings. Aggregate and analyze audit findings into a reportable format for management use. • Maintain accurate recordkeeping of all delegation oversight audits and ensure all deadlines are met. • Assist in the revision of delegation oversight audit tools in accordance with standards set by ICE, NCQA, the Plan's policies and procedures and other State and Federal guidance tools as required. • Participates in Joint Operations Committee (JOC) meetings. • Participates in the Compliance Committee meeting.
Skills Required : POSITION QUALIFICATIONS Competency Statement(s) • Analytical Skills - Ability to use thinking and reasoning to solve a problem. • Technical Aptitude - Ability to comprehend complex technical topics and specialized information. • Problem Solving - Ability to find a solution for or to deal proactively with work-related problems. • Communication, Written - Ability to communicate in writing clearly and concisely. • Communication, Oral - Ability to communicate effectively with others using the spoken word. • Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type. Demonstrated proficiency in Microsoft Word, Excel, Access, and PowerPoint.
Experience Required: Experience: 3 plus years of experience in an audit, compliance or delegation oversight role; preferably in a managed care environment.
Education Required:High School Graduate or General Education Degree (GED): Required Bachelor's Degree (four year college or technical school) Required, Field of Study: BSN, Business, Health Sciences, Managed Care Registered Nurse (RN).: Required
.Ability to establish, nurture and maintain strong and effective working Requirements: relationships with the GCHP and Delegated Entity staff; Ability to maintain detailed and accurate records, follow oral and written directions, prepare written agendas and transcribe minutes; Ability to operate a keyboard and sit for long periods; ability to read close-up and do close-up work; ability to perform repetitive motion (keyboard); writing (note-taking); ability to hear normal speech, hear and talk on telephone; Ability to think and work effectively under pressure; Ability to deal with public contact; decision making, concentration.
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