Compliance Delegation Nurse
Listed on 2026-02-01
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Healthcare
Healthcare Management
About Us
All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules.
ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. Additional employee paid coverage options available. We also offer paid holidays, birthday off, and unlimited PTO as well as a 401k plan.
The Compliance Delegation Nurse ensures that sub-delegated entities meet regulatory, contractual, and organizational standards related to clinical care and utilization management. This includes oversight of functions delegated under Health Plan, Medicare Advantage contracts and ensuring alignment with NCQA accreditation standards. The role involves auditing, monitoring, education, and collaboration to ensure quality and compliance in sub-delegated functions.
Duties and responsibilities- Maintains an unrestricted CA Registered Nurse and Texas license
- Conduct pre-delegation and annual oversight audits of delegated entities to ensure compliance with CMS Medicare Advantage requirements and NCQA standards for utilization management and case management.
- Evaluate clinical documentation and utilization decisions for adherence to evidence-based guidelines and regulatory expectations. (this would include new staff and current staff)
- Monitor and track corrective action plans (CAPs) to ensure delegated entities timely resolution of deficiencies.
- Ensures that delegated entities implement their Corrective Action Plans by specified due dates by following up as needed.
- Collaborate with internal departments (e.g., Compliance, Quality, Care Management) and external delegated entities to ensure alignment with contractual and regulatory obligations.
- Participate in ACTY Compliance meetings.
- Advise leadership on compliance risks and recommend policy improvements.
- Prepare and submit reports to internal committees, leadership and regulatory bodies.
- Provide training and technical assistance to delegated entities on Medicare Advantage, Health plan NCQA UM and Case Management requirements and other regulatory requirements
- Support readiness for Health Plan program audits for the Care Management department. and other external reviews.
- Conducts IRR reviews on all clinical staff for ACTY and the delegates as needed.
- Trains new staff on compliance requirements for UM and Case Management.
- Responds to corrective actions plans (CAPS) in collaboration with VP.
- Assists with audits for health plans.
- Maintains documentation in ACTY tracking platform of care management audits, findings and follow-ups.
- Identifies areas of improvement to Director and/or Vice President.
- Follow up and coordinate the Care management compliance responses. Maintain current knowledge of CMS regulations, NCQA standards, and state-specific requirements impacting delegated functions.
- Works with Chief Medical Officer, Director, UM Committees
- Maintain confidentiality and follow HIPAA policies
- Be courteous and promote professionalism
- Be flexible and adaptable
- Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe
- Detail oriented and highly organized
- Strong ability to multi-task, project management, and work in a fast-paced environment
- Strong ability in problem-solving
- Ability to self-manage, strong time management skills
- Ability to work in an extremely confidential environment
- Strong written and verbal communication skills
- Minimum 5 years clinical practice
- Possesses at least three years of managed care experience in an IPA/HMO/Medical Group
- Possesses excellent communication skills and negotiation skills
- Possesses excellent organizational skills
- Possesses leadership skills
- Holds Current Unrestricted California Registered Nurse License and Texas License
- This job may require flexible work hours due to the nature of the responsibilities
- Candidate must be comfortable with ambiguity and open to working in a collaborate environment
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