Delegation Operations Nurse Auditor - LVN, Experienced
Blue Shield of California
- Long Beach, CA
- $71,280-99,770 per year
- Permanent
- Full-time
- 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
- 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