Job: Delegation Oversight Specialist

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Job Description

Delegation Oversight Specialist


Daily Schedule-Days
Scheduled Hours per 2-week Pay Period-80
Weekends Required -None


Theprimary role of the MA Delegation OSpecialist is to assist the MA DelegationOversight Manager in oversight, administration, and maintenance of Medicare delegatedfunctions and in compliance with Medicare guidelines across all Qualchoice Healthplans.


Essential Duties and Responsibilities

·       MaintainCMS compliance in all activities performed.

·       Developand maintain training materials to assist with communication and education ofinternal and external stakeholders on oversight processes.

·       Lead regulatory reporting data auditing in partnership withcross-functional entities

·       Ability to think critically and often independently to identifytrends, concerns, and processes that may not be well-defined.

§  Must bewilling to ask well-formulated, thought-out questions seeking input whenambiguity may exist.

·       Perform audits, support audit process development of Medicare functionsdelegated to external entities, and draft descriptive audit reports outliningfindings including but not limited to:

§  Claimspayment for medical and pharmacy processes

§  Organizationdeterminations to ensure proper classification, communication, and effectuationof requested services.

§  Coverage determinationsto ensure effectuation, member and provider letter language, and clinicaldecision making are compliant with CMS guidance.

§ ESRDand Hospice claims to ensure appropriate oversight of appropriate benefitutilization

§ Vision,dental, and required or optional supplemental benefit providers to ensureproper benefit administration and claims payment.

§ MedicationTherapy Management Program to ensure vendor compliance with administration withmedication therapy management, qualifications and adherence to CMS guidelines.

·       Developand maintain initiatives to support Fraud, Waste, and Abuse monitoring toidentify and investigate providers, pharmacies, and delegates of concern.

§ Investigateand escalate issues when applicable

§ Liaisewith Compliance to support Compliance Program Effectiveness activities

·       Support delegation oversight by working with stakeholders to trackcompliance concerns and developing controls to mitigate risk for delegatedfunctions.

·       Investigateand track to completion potential delegation issues related to potential FWA,non-compliance and escalate to Compliance when applicable

·       Assist cross-organizationally with educating delegates, providers,and pharmacies on the health plan's delegation oversight processes.

·       Assist with the pharmacy utilization review and reporting processes.

·       Perform data analysis to monitor success of Compliance Improvementinitiatives for quality of Medicare related projects.

·       Serve as a liaison between delegation oversight department andcross-functional areas for process and policy development.

Education and Experience* Demonstrated and articulated growth mindset for taking on challenges and developing solutions* Ability to work effectively in a fast-paced, dynamic environment where clear processes may not yet be established required.* Associates Degree or equivalent work experience.* 5+ years work experience in managed care, health plan, or PBM environment, preferably Medicare* Broad-based, working knowledge of managed care clinical operations required.* Moderate to advanced working knowledge of Microsoft Office (e.g. Outlook, Excel, Word, etc.)* Demonstrated excellent customer service skills with both internal and external customers.* Strong abilities in verbal and written communication with diverse audiences required.* Demonstrated experience with effective time management working with minimal supervision and successful handling of multiple projects simultaneously and prioritize work appropriately.* Experience working with all levels of staff and medical practitioners including members, physicians, nurses, and providers.* Demonstrated self-starting initiative in organizing and prioritizing work to meet deadlines.Certificates, Licenses and Registrations* WA State Pharmacy Technician registration/license preferred, but not required.  
We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.  

Requisition Title

QualChoice Health