Job ID: 147111
We are actively seeking Quality Auditing Registered Nurse to join our team in Rancho Cucamonga, CA ASAP! We are a large health plan with several locations throughout the state!
If you’re interested in hearing more, please apply today!
The Audit Nurse Specialist is responsible for monitoring and reporting compliance issues for the external delegated functions of Case Management (CM), Disease Management (DM), and Model of Care (MOC), interfacing with health plans, and oversight of health plan delegated reports.
· Interfaces with health plans and acts as liaison for delegated services
· Reviews delegation agreements and has a clear understanding of delegated services and reporting requirements
· Anticipates plan requirements and proactively works on solutions to meet requirements
· Serves as a resource for complex issues and performs analysis and provides solutions for resolution
· Has authority to approve deviations from standard procedures related to complex issues
· Serves as the primary contact and delegation resource for health plans
· Manages the external audit process end to end to include routine delegation as well as new payer pre-delegation
· Plans in advance for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirements.
· Coordinates onsite visit and facilitates meetings and audit process
· Prepares and submits document requests and case universes
· Prepares and audits file requests based on regulatory and accreditation requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before the audit
Monday - Friday 8a-5p
Advantages of this Opportunity:
· Salary is based on experience, tenure, certifications etc. (very competitive with market place)
If you’re interested in speaking in more detail, please apply today! We are scheduling interviews ASAP.
- MUST be RN with clear/active license in CA
- 2+ years of auditing experience with a background in quality/auditing - NCQA, MOC, CMS
- 2 years of Utilization Management experience