Registered Nurse (RN) - Med Surg
Blue Cross and Blue Shield Association
Philadelphia, PA

Delegation Oversight Specialist - RN

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. This Delegation Oversight Specialist - RN role involves oversight of delegated activities to ensure compliance with NCQA accreditation standards, CMS, and state regulatory requirements. Ideal candidate will be an excellent communicator (written and verbal) who is detail oriented, organized, able to read and interpret regulations and able to meet tight deadlines while handling multiple audits. Responsibilities include: * Coordinates, conducts and documents required pre-delegation assessments and annual NCQA assessments as necessary to comply with applicable state, federal and accreditation requirements, * Conducts necessary monitoring and auditing work to ensure vendors comply with state, federal, NCQA and other applicable requirements. * Review reports from Delegated Entities. * Develops corrective action plans when deficiencies are identified and document follow-up to completion. * Present delegate's performance to respective committees, including the preparation of documents for committee oversight of delegated functions. * Review implementation of new or changed regulatory requirements to help ensure adequacy of controls of oversight activities * Provide guidance of new or changed regulatory requirements and implementation of processes. * Analyzes and interprets existing and proposed legislation and regulations and determines their effects on delegation oversight process. * Conduct risk assessments to identify required audit areas and audit frequency. * Assist in developing audit tools of oversight activities. * Work collaboratively with Delegation Manager/Director to develop, establish and maintain departmental processes and procedures. * Performs other duties as required. Qualifications: * Active, unrestricted RN license * Experience with either Utilization Review and/or Case Management * Three years auditing experience using NCQA guidelines preferred * Experience in delegation oversight process and working knowledge of Part C Organization Determination regulations and NCQA Health Plan standards preferred * Intermediate proficiency in the use of Office365 (e.g. Word, Excel) required. Hybrid Independence has implemented a "Hybrid" model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the "Hybrid" model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania.