Delegation Management Nurse

Overview:

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

***This position is work from home within California.

Position Summary:

The Delegation Management Nurse is responsible for overseeing and managing the delegation of healthcare services to third-party providers within the Managed Services Organization (MSO). This position ensures that delegated entities comply with regulatory requirements, maintain high-quality care standards, and adhere to established contractual obligations. The nurse will work closely with clinical teams, providers, and third-party delegates to monitor performance, conduct audits, and implement corrective actions as necessary

Responsibilities may include:

- Monitor and assess the performance of delegated entities by conducting regular audits and reviews.
- Ensure compliance with federal, state, and local regulations, including CMS, NCQA, and DHCS standards.
- Collect and analyze data, reports, and case files from third-party providers (IPAs) to evaluate compliance with healthcare standards and regulations.
- Track and address deficiencies through corrective action plans (CAPs).
- Act as the primary clinical liaison for delegated entities, providing guidance on MSO policies, procedures, and clinical processes.
- Ensure clear communication and interpretation of regulatory requirements.
- Lead and support pre-delegation audits, annual audits, and ongoing reporting for delegated services.
- Prepare detailed documentation, reports, and presentations for internal stakeholders and external regulatory audits.
- Serve as a subject matter expert in interpreting compliance requirements, ensuring that all operational areas adhere to health plan and regulatory standards (e.g., NCQA, CMS).
- Develop, issue, and monitor the implementation of Corrective Action Plans (CAPs) for identified deficiencies.
- Work closely with delegates to ensure timely resolution and closure of CAPs.
- Work collaboratively with provider services, utilization management, case management, and other internal departments to ensure cohesive and compliant operations across delegated services.
- Track and trend non-compliant areas impacting delegated functional area departments.
- Interpretation, dissemination, and logging of regulatory guidance and education.
- Assess risks associated with delegated activities and implement strategies to mitigate them, ensuring that high-quality patient care is maintained.

Minimum Qualifications:

- 3 years managed care experience
- 1 year minimum of UM Delegation Oversight audit experience with Health Plan or large MSO
- Case Management experience
- Graduate from an accredited school for Nursing
- Clear and current CA Licensed Vocational Nurse (LVN)
- Knowledge in NCQA standards, DHCS, CMS, and DHMC regulatory requirements

Preferred Qualifications:

- 3-5 years UM/Case Management delegation oversight audit experience with a Health Plan or large MSO
- Clear and current CA Registered Nurse (RN)
- Bachelor of Science in Nursing (BSN)
- Certified Healthcare Privacy Compliance (CHPC)