JOB SUMMARY

The Delegation Oversight Nurse is responsible for the delegation oversight activities of all Health Services Department (HSD) delegated vendors including Appeals & Grievances, Case Management and Utilization Management. This position ensures all delegated entities are following all federal, state, and local laws and accreditation requirements as well as contractual obligations. The Delegation Oversight Nurse is responsible for the completion of delegation oversight audits and logs, identification of gaps and initiation of corrective action plans in conjunction with the HSD Directors and Compliance.

ESSENTIAL FUNCTIONS OF THE ROLE

Completes monthly audits of all HSD department delegates and documents all findings on the delegation oversight logs.

Oversees and ensures compliance with state/federal regulatory and accreditation requirements. Researches regulatory and accreditation changes and the impact to business; provides regular updates to HSD Leadership and Compliance.

Assists in the development of appropriate audit tools. Conducts and reports on audits as assigned to assist in management's documentation of compliance with regulatory, accreditation and operational process improvement standards.

Prepares a summary of audit findings and communicates significant findings to management in a timely manner following audit completion. Prepares and submits documentation of required follow-up reviews on previous audit findings. Conducts follow-up reviews to assess and verify effectiveness of any implemented action plans.

Presents delegation oversight findings/activities in collaboration with internal stakeholders.

Works collaboratively with department leadership to identify significant findings and prepare corrective action plans (CAPs).

Works with Compliance to finalize CAPs, deliver them to the delegated entities and follow up on closure of the CAPs.

Works with Compliance on behalf of HSD departments in the completion of the annual delegation risk assessments as well as in the annual delegation auditing activity.

KEY SUCCESS FACTORS

Experience with MCO (Managed Care Organization) operations relative to care management, utilization management or appeals and grievances.

Must have a working knowledge of key quality and regulatory organizations, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Institute for Healthcare Improvement (IHI), the National Association for Healthcare Quality (NAHQ) and the National Committee on Quality Assurance (NCQA), Texas Department of Insurance (TDI), Health and Human Services Commission (HHSC), Centers for Medicare and Medicaid Services (CMS) and the Department of Labor.

Knowledge of internal quality controls in compliance with department policies and procedures.

Must be able to communicate thoughts clearly, both verbally and in writing.

Interpersonal skills to interact with a wide range of constituencies.

Must have critical thinking and problem-solving skills.

Ability to pay attention to detail with emphasis on reporting skills.

Ability to balance multiple demands and respond to time constraints.

General computer skills, including but not limited to: Microsoft Office, information security, electronic medical documentation, and email.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - Associate's

- MAJOR - Nursing

- EXPERIENCE - 3 Years of Experience

- CERTIFICATION/LICENSE/REGISTRATION -
       Registered Nurse (RN)

Return to Search Results