Compliance Delegation Nurse

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. 

Job purpose

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

Qualifications                                

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

Education and Additional Requirements                                    

Holds Current Unrestricted California Registered Nurse License and Texas License

Working conditions

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