One of Insight Global's client is looking for a Nurse Auditor to join their team. This person coordinates, conducts and documents required pre-delegation assessments and annual audits. They will serve as primary point of contact related to delegation oversight. This person will also conduct necessary monitoring and auditing work to ensure delegates comply with state, federal, NCQA and other applicable requirements.
Review reports from Delegated Entities. Other responsibilities include:
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
Regularly assess metrics to evaluate delegate's performance
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 management to develop, establish, and maintain departmental processes and procedures.
Schedule is Mon-Fri 8-5
1+ years with Utilization Review, Nurse Auditing and/or Case Management
Knowledge of audit process and applicable state and federal regulations (NCQA Health Plan standards)
Comfortable commuting with to Philadelphia a few times a year (3-6 visits predicted at most). This will be based on project work.
Behavioral health experience - handling claims or cases
Experience in delegation oversight process and working knowledge of Part C Organization Determination regulations
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.