Job Description

Compliance Specialist - Delegation Oversight

Location: Philadelphia, PA (must hold active, unrestricted PA RN license)

Type: Contract

Overview:

The Delegation Oversight Specialist – RN plays a key role in ensuring that all delegated activities by vendors—such as Utilization Management (UM), Case Management (CM), and Appeals—are performed in full compliance with regulatory, contractual, and accreditation standards. This position is responsible for conducting comprehensive assessments, audits, and ongoing monitoring to uphold the organization’s commitment to quality, compliance, and member safety.

Key Responsibilities:

• Lead the oversight of delegated vendor activities (UM, CM, Appeals) to ensure compliance with federal, state, NCQA, and other applicable regulations.
• Conduct pre-delegation assessments, ongoing audits, and performance reviews of assigned vendors.
• Prepare detailed audit reports and present findings to the Delegation Oversight Committee.
• Develop and monitor Corrective Action Plans (CAPs) for identified deficiencies, ensuring timely resolution and continuous improvement.
• Track and verify receipt and completeness of required vendor reports to ensure compliance with reporting standards.
• Maintain documentation and evidence required for delegation readiness reviews and ongoing compliance audits.
• Collaborate with internal teams and external vendors to support continuous quality improvement and regulatory readiness.

Qualifications:

• Education: Active, unrestricted Registered Nurse (RN) license in Pennsylvania (required).
• Experience: 3–5 years of experience in regulatory, accreditation, or compliance roles within the health insurance, healthcare, or managed care industry.
• In-depth knowledge of federal and state healthcare regulations, NCQA standards, and delegation oversight requirements.
• Strong understanding of ACA and Medicare programs, including Qualified Health Plans (QHP) and Medicare Advantage compliance requirements.

Skills & Competencies:

• Exceptional attention to detail and organizational skills.
• Excellent written and verbal communication abilities, including audit reporting and presentation.
• Strong analytical and problem-solving skills.
• Proven ability to manage multiple projects and competing priorities in a fast-paced environment.
• Advanced Microsoft Excel skills, including data organization, formulas, and report generation.

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