Compliance RN - Delegation Oversight (Philadelphia)

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 vendorssuch as Utilization Management (UM), Case Management (CM), and Appealsare 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 organizations 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 :

Skills & Competencies :