Delegation Oversight Clinical Auditor

As a Clinical Auditor for the UCLA Health
Medicare Advantage Plan, you will independently assess whether delegated
clinical decisions and services are appropriate for members and supported by
the clinical record.

Reporting to the Associate Director of
Delegated Oversight & Systems, you will serve as the clinical subject
matter expert for the review of services performed by contracted Independent
Physician Associations (IPAs) and other delegated entities. Your work will span
utilization management, case management, population health management, disease
management, behavioral health, transitions of care, and related quality
activities.

In this role,
you will:

We're seeking a detail-oriented nurse with:

Required:

• A Bachelor's degree in Nursing
• An Active unrestricted California Registered
  Nurse (RN) license
• 5 or more years of experience in nursing,
  including managed care, health, plan, utilization management, behavioral
  health, or related operations
• 3 or more years of experience performing
  utilization management, care management, population health, clinical quality
  review, clinical audit, or delegated clinical oversight
• 3 or more years of experience conducting
  clinical record review, medical necessity review, denial review, audit testing,
  or validation of clinical decisions and documentation
• Knowledge of Medicare Advantage delegation
  oversight requirements, plan accountability for delegated services, and
  applicable CMS, DMHC, NCQA, and OIG compliance guidance
• Clinical knowledge of Utilization Management,
  Case Management, Population Health Management, Disease Management, Behavioral
  Health, and Transitions of Care
• Ability to distinguish administrative or process
  completion from clinical appropriateness and independently perform the clinical
  component of oversight reviews
• Ability to evaluate assessments, risk
  stratification, care plans, interventions, referrals, follow-up, transitions,
  and escalation against identified member needs and source evidence
• Knowledge of medical necessity review principles
  and ability to evaluate clinical rationale, documentation, criteria
  application, and timeliness in authorization and denial files
• Ability to plan and conduct pre-delegation,
  annual, and focused clinical audits using source records, policies, committee
  evidence, and delegated entity submissions
• Ability to identify clinical, compliance, and
  documentation deficiencies; synthesize findings; and recommend clear corrective
  actions and risk escalation
• Ability to validate corrective action
  effectiveness through follow-up testing, evidence review, performance
  monitoring and trend analysis
• Strong written communication skills for clinical
  audit reports, findings, corrective actions, scorecards, committee materials,
  and executive summaries
• Strong verbal communication and stakeholder
  management skills with delegated entities and internal clinical, compliance,
  quality, and operational partners
• Ability to exercise independent professional
  clinical judgement while maintaining objectivity, consistency, confidentiality,
  and audit-defensible documentation
• Ability organize regulatory and accreditation
  evidence and support CMS and accreditation audit readiness activities
• Proficiency with Microsoft Office applications
  and enterprise collaboration or documentation repositories used to perform and
  document oversight work

Preferred:

• A Master's degree in Nursing, Public Health,
  Healthcare Administration, or a related field
• Certified Professional in Healthcare Quality
  (CPHQ) or Certified Case Manager (CCM)
• Training in CMS, NCQA, healthcare compliance,
  utilization management or clinical audit
• 3 or more years of experience supporting
  Medicare Advantage, CMS, DMHC, NCQA, accreditation, compliance, or delegation
  oversight reviews.
• 3 or more years of experience developing
  clinical findings, corrective actions, follow-up testing, trend analysis, or
  remediation validation