SCAN Health Plan Looking for DHCS Facilities Site Review Auditor – RN (Remote/Field – San Diego County) at San Diego, CA  Full Time

**Remote/Field in San Diego County Territory**

** Eligible for 10K sign on bonus, if DHCS-CSR (certified site reviewer)**

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit , , or follow us on LinkedIn, Facebook, and Twitter.

The Job

Performs all aspects of oversight requirements to test, monitor, document and report the overall level of compliance with CMS and local requirements for Utilization Management achieved by First Tier, Downstream and related entities (FDR) to ensure compliance with all SCAN, Federal, State and National Committee for Quality Assurance (NCQA) requirements and guidelines while maintaining effective professional relationships and acting as a liaison, including the SCAN UM operations.

You Will

Perform on-site and desktop auditing of FDRs including SCAN’s delegated groups, IPA’s, hospitals’ and ancillary provider’s utilization management (UM) processes and standards using clinical judgment and standardized assessment tools.

Prepares detailed written results of oversight audits by communicating findings, areas of concern and recommendations for improvement, including corrective action requests in accordance with P&P’s.

Conducts closing meetings with FDRs to give them a preliminary overview of completed compliance audits. Respond to FDRs as disagreements with audit findings arise. Communicates regulation interpretations and explains their application. Provides supplemental information if needed.

Conducts all aspects of annual oversight projects, including creation and distribution of mass mailing and individual correspondence, coordination of projects with internal SCAN staff and departments, monitoring and reporting delegated compliance, tracking, trending and reporting upon project status, coordinating with Compliance regarding report submissions and HPMS/regulatory updates.

Functions as the UM compliance subject matter expert by representing the Delegation Oversight Unit (DOU) in interdepartmental meetings and partnering with Compliance to develop and implement SCAN policy regarding NCQA, DHCS, CMS and/or other regulatory revisions. Escalates longstanding issues of non-compliance in accordance with P&P’s.

Educates FDRs, SCAN staff and Compliance Auditors on such topics as UM delegated requirements in accordance with CMS, local state and SCAN contractual requirements.

Reviews UM processes with regulatory and contractual requirements, and recommends delegated status based on results. Ability to recognize and communicate areas for improvement to the FDR enabling them to meet UM compliance standards.

Makes revisions and recommendations for improvement of policies and procedures, as well as work flow charts for the DOU.

Assists providers in achieving and maintaining compliance with SCAN, Federal, State and NCQA requirements and guidelines including the development and implementation of corrective action plans (CAP), monitoring CAP activities and providing education and tools exercising clinical judgment.

Analyzes self-reported monthly/quarterly QM/UM work plans by FDRs, including the request for corrections from FDRs as needed.

Conducts detailed review, analysis, and interpretation of legislative, statutory, regulatory, and contract language.

Using critical thinking skills, identifies impactful areas for UM compliance to develop an effective implementation communication plan.

Assists and participates in regulatory audits, including preparation and monitoring of any corrective action plans.

May conduct Facility Site Reviews (FSR) consistent with Department of Health Care Services (DHCS) requirements, reports results and recommendations to the SCAN Network Performance Committee (NPC), provides education and support to providers to ensure compliance standards are met.

Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers and brings to the attention of the supervisor/manager.

Maintains the member’s right to privacy and protects SCAN operations by keeping information confidential.

Adheres to all quality, compliance and regulatory standards to achieve HCS and SCAN outcomes

Actively supports the achievement of SCAN’s Vision and Goals

Contributes to team effort by accomplishing related results as needed.

Actively supports the achievement of SCAN’s Vision and Goals.

Other duties as assigned.

Your Qualifications

Registered Nurse required (current and active California license in good standing). Bachelor’s Degree in Nursing or related field preferred.

3+ years Clinical experience including but not limited to ER/Acute Care nursing required. IPA, Medical Group experience preferred.

2+ years of case management/managed care experience preferred.

Prior auditing experience preferred.

Basic knowledge of related NCQA standards, CMS and DHCS regulations.

Excellent written and verbal communication skills.

Strong independent analytical, critical thinking, problem solving, and decision making skills.

Strong attention to detail and organizational skills.

Strong customer service skills.

Ability to prioritize multiple and competing tasks in a fast paced environment.

Must be able to work independently as well as in a team environment.

Proficient in MS Office and data entry.

Strong contract interpretation skills.

Moderate travel in the assigned area (San Diego County) – Must have a valid driver’s license, automobile insurance and reliable transportation.

What’s in it for you?

• Base salary range: $34.47 to $55.14 / hour
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Ten paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We’re always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

#LI-CS2

#LI-Hybrid