Job Title

JOB DESCRIPTION Job Summary Provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant with all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. We are looking for LVN's with at least 4 years of UM experience, NCQA accreditation, and knowledge of InterQual / MCG guidelines. Excellent computer knowledge, multi-tasking skills and analytical thought process is important to be successful in this role. Productivity is important with quick turnaround times. Experience with Appeals, Auditing, and Compliance /Quality will be a good fit for this position. Strong UM Prior Authorization experience highly preferred. Further details to be discussed during our interview process. CA located u2013 Remote position Work hours: Monday u2013 Friday 8:00am u2013 5:00pm PST CA LVN licensure required Essential Job Duties u2022 Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. u2022 Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. u2022 Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. u2022 Assists with delegation oversight committee meetings. u2022 Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. u2022 Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. u2022 Participates as needed in joint operation committees (JOCs) for delegated groups. u2022 Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications u2022 At least 3 years experience in health care, including 2 years experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. u2022 Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). License must be active and unrestricted in state of practice. u2022 Knowledge of audit processes and applicable state and federal regulations. u2022 Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. u2022 Ability to collaborate effectively with team members and internal departments. u2022 Strong attention to detail with a focus on maintaining quality in all tasks. u2022 Strong verbal and written communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications u2022 Registered Nurse (RN). License must be active and unrestricted in state of practice. u2022 Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $68,640 - $123,164 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.