Delegation Oversight LVN – Utilization Management

Job Summary

Join Our Growing Clinical Team

We are seeking an motivated and experienced detail - orientated Delegation Oversight LVN to join our team!

This is an excellent opportunity for an experienced managed care professional who enjoys analyzing data, conducting audits, solving complex operational issues, and building strong relationships with delegated partners.

In this highly visible role, you will help oversee Utilization Management activities performed by contracted IPAs, medical groups, MSOs, and other delegated entities. You will collaborate with clinical leaders, internal departments, and external partners to promote regulatory compliance, strengthen performance, and support appropriate and timely care. This position offers an exciting opportunity to influence healthcare delivery through effective oversight, data analysis, and team collaboration.

Key Responsibilities

• Monitor delegated Utilization Management activities for compliance with contractual, regulatory, accreditation, and Champion Health Plan requirements.
• Review and validate authorization data, timeliness reports, denial information, dashboards, and other required submissions.
• Audit Table 1 universes and supporting data at least quarterly, including data validation and review of denial notices.
• Review Organization Determinations, Appeals, and Grievances reporting data and identify potential discrepancies.
• Participate in pre-delegation, annual, focused, and ad hoc audits of IPAs, medical groups, MSOs, and other delegated entities.
• Prepare audit tools, findings, summaries, and supporting documentation.
• Identify compliance deficiencies, performance trends, and member-impacting concerns and communicate findings to leadership.
• Develop, issue, monitor, and validate Corrective Action Plans in partnership with leadership and delegated entities.
• Maintain audit schedules, oversight trackers, monitoring tools, CAP logs, and supporting documentation.
• Assist with CMS, DMHC, NCQA, health plan, accreditation, and delegated-entity audits and reviews.
• Collaborate with Utilization Management, Care Management, Quality, Compliance, Provider Services, Claims, Appeals and Grievances, and Network Management.
• Participate in Joint Operations Committee and delegation oversight meetings and provide updates regarding performance and outstanding issues.
• Provide guidance to less-experienced staff regarding delegation oversight, audit preparation, documentation, and regulatory requirements.
• Support the development and implementation of policies, procedures, workflows, audit tools, and training materials.
• Maintain the confidentiality of protected health information and comply with HIPAA and Company privacy, security, and compliance requirements.

Required Qualifications

• Current, active, and unrestricted California Licensed Vocational Nurse license.
• At least five years of progressive managed care experience involving Medicare Advantage, Utilization Management, delegation oversight, case management, health plan operations, or a related area.
• Strong knowledge of authorization review, concurrent and retrospective review, referral management, delegated Utilization Management, and regulatory requirements.
• Experience reviewing healthcare data, reports, case documentation, denial notices, and operational metrics for accuracy and compliance.
• Ability to independently investigate discrepancies, document findings, monitor corrective actions, and escalate concerns appropriately.
• Strong analytical, organizational, problem-solving, interpersonal, and written communication skills.
• Ability to manage multiple audits, priorities, deadlines, and follow-up activities with minimal supervision.
• Proficiency with Microsoft Excel, Word, Outlook, Teams, and managed care or authorization systems.

Pay: From $37.00 per hour

Benefits:

• 401(k)
• AD&D insurance
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person