Manager, Delegation Oversight Clinical Audit
2 weeks ago
Salary Range: $117, Min.) - $152, Mid.) - $188, Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The Manager, Delegation Oversight Clinical Audit is directly responsible for the oversight and monitoring functions for contracted providers, Participating Provider Groups (PPG), Plan Partners, and specialty health plans. The Delegation Oversight Clinical Audit Program activities include auditing delegated activities for compliance with State and Federal contractual compliance (CMS and DHCS) as well as accreditation standards (NCQA). The oversight activities include auditing delegated functions, performance monitoring for corrective actions, and reporting activities for internal committees as well as regulatory agencies. The position works closely with the Director, Delegation Oversight Audit on clinical issues/clinical review and interfacing with external agencies including other Local Initiatives, PPGs, and Health Plans. The position is further responsible to ensure all functions are operating in accordance with the organization's mission, values and strategic goals, are focused on continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.
DutiesResponsible for the oversight and performance monitoring of the delegated PPGs and Specialty Health Plans. Reporting FWA accordingly as defined by department policy.
Assures departmental compliance with: Contract delegation agreements for all applicable regulations & standards as well as CMS, DHCS and NCQA.
Oversees and audits operational compliance with organizational standards, policies and procedures and regulatory requirements. Ensures required standards including coordination of activities with other departments to achieve full compliance.
Assists in the development of and is responsible for the implementation of departmental objectives to support organization strategies.
Implements and enforces approved departmental policies and procedures/workflows.
Develops and maintains departmental statistical and performance reports. Facilitates data flow, analyzes, reports, design formats, interprets data and recommends alternatives/solutions internally and externally. Implements and monitors departmental performance standards.
Performs ongoing monitoring and evaluation of clinical audit to assure optimal efficiency and effectiveness. Assists in identification of and is responsible to implement clinical audit modifications to enhance departmental performance. Requests assistance from Delegation Oversight Audit Director as needed to accomplish goals. Implements, with approval, programs that improve the provision of services to members.
Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.
Assures appropriate department interface with CMO, Medical Director and Physician Advisors. Works collaboratively with other LA Care departments to improve Service Quality and Clinical Quality provided to members and to enhance the overall operational performance and efficiency of L.A. Care. Identifies performance issues or opportunities for improvement within delegated clinical operations that impact compliance. Maintains and provides input for the departmental budgets.Duties Continued
Human Resource Management: Daily staff supervision and oversight. Develops and maintains a culturally sensitive work environment that promotes staff growth and education. Completes performance appraisals in accordance with established policies and based upon achievement of the L.A. Care mission, value, objectives and management expectations. Assures staff have access to appropriate training and educational opportunities. Recruits appropriately qualified candidates, with approval of Director. Counsels and coaches staff in consultation with Delegation Oversight Audit Director and in conjunction with HR. Participates in the hiring and termination of staff with the Delegation Oversight Audit Director and in conjunction with HR.
Responsible for oversight and adequate performance of delegated activities.
Collaborates with Utilization Management (UM), Provider Network Operations and Quality Dept.'s staff on identifying topics and agenda items for the trainings.
Maintains and audits schedules on an annual or as needed, basis. Prepares quarterly utilization/quality reports for the Delegation Oversight Committee, Quality Committees, Sanctions Committees, and Internal Compliance Committees.
Performs other duties as assigned.
Education Required
Bachelor's Degree in NursingEducation Preferred
Master's Degree in Healthcare Related FieldExperience
Required:
At least 6-8 years of experience in clinical auditing or health care with a focus in areas of Utilization Management claims.
At least 3-5 years of supervisory/management experience in a related capacity.
At least 3 years relevant health plan or managed care experience.
Audit/oversight experience.
Experience with Medi-Cal and Medicare populations and regulatory requirements.
Advanced working experience with Health Care Information Technology Systems and with advanced software programs such as Excel, PowerPoint and relational databases.
Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
SkillsRequired:
Excellent verbal and written communication skills.
Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.
Strong problem solving, planning, and organizational skills.
Demonstrates reliability and good attendance and punctuality standards.
Persuasion Skills: Ability to influence CA staff/other department staff to work together to ensure compliance, business processes and member/provider satisfaction.
Advanced skills in software programs such as Excel, Power-point and relational data bases.
Licenses/Certifications RequiredRegistered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred
Nurse Practitioner (NP)- Active, current and unrestricted California LicenseCertified Professional in Utilization Review (CPUR)Certified Case Manager (CCM)Certified Professional in Healthcare Quality (CPHQ)Required Training
Physical Requirements
LightAdditional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
-
Delegation Oversight Clinical Auditor RN II
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Manager, Care Management
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $117, Min.) - $152, Mid.) - $188, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Senior Director II, Regulatory Operations
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $171, Min.) - $232, Mid.) - $292, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Manager, Medical Management
2 months ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $117, Min.) - $152, Mid.) - $188, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Manager, Regulatory Audits
3 weeks ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $102, Min.) - $132, Mid.) - $163, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Manager, Enhanced Care Management
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $117, Min.) - $152, Mid.) - $188, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Clinical Operations Executive
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $206, Min.) - $278, Mid.) - $350, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Credentialing Professional
8 hours ago
Los Angeles, California, United States The Judge Group Inc. Full timeLocation: REMOTESalary: $18.00 USD Hourly - $22.00 USD HourlyDescription: A Prestigious client is currently seeking a Remote Credentialing Professional This job will have the following responsibilities:Perform duties related to organizational and individual provider credentialing, caregiver background checks, and delegation oversight audits for Medicare,...
-
Audit and Tax Intern
6 days ago
Los Angeles, California, United States CBIZ Full timeWith over 120 offices and nearly 7,000 associates throughout the U.S. CBIZ (NYSE: CBZ) delivers top-level financial and employee business services to organizations of all sizes, as well as individual clients, by providing national-caliber expertise combined with highly personalized service delivered at the local level. CBIZ has been honored to be the...
-
Quality Assurance Specialist II
6 days ago
Los Angeles, California, United States Advanced Clinical Full timeOVERVIEWWe are currently searching for a skilled professional to join a well-known client's team as a Quality Assurance Specialist II in Los Angeles, California. This onsite role will support Quality Management Systems, donor chart review, tissue release, complaints, and other process improvements. Apply today to talk with one of our recruiters and learn...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $67, Min.) - $87, Mid.) - $107, Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $67, Min.) - $87, Mid.) - $107, Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Clinical Research Coordinator III
6 days ago
Los Angeles, California, United States Cedars-Sinai Full timeJob DescriptionCome join our teamThe Clinical Research Coordinator III (CRC-III) provides support from initiation through closeout for all Guerin Children's clinical research studies, including ancillary service coordination, patient recruitment and enrollment, data collection, and compliance assurance. The CRC-III is an experienced coordinator with ample...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $67, Min.) - $87, Mid.) - $107, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $67, Min.) - $87, Mid.) - $107, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Senior Psychologist Program Manager
1 month ago
Los Angeles, California, United States Department Of Veterans Affairs Full timeSummary Senior Psychologist Program Managers generally manage large, complex programs. The Workplace Violence Prevention Program (WVPP) for GLA is a highly specialized, complex network of large programs & encompasses numerous component parts that are integral to the creation & maintenance of workplace safety & accountability throughout the GLA facility. The...
-
District Clinic Manager Los Angeles
6 days ago
Los Angeles, California, United States Hydration Room, Inc. Full timeDescription:The District Clinic Manager will be supervising retail and non-medical operations within a multi-unit portfolio of clinics by planning strategies and consistent implementation to achieve results. We are seeking an experienced retail operator with extensive sales and customer service history.The District Clinic Manager position will be a full...
-
District Clinic Manager Los Angeles
6 days ago
Los Angeles, California, United States Hydration Room, Inc. Full timeDescription:The District Clinic Manager will be supervising non-medical operations within a multi-unit portfolio of clinics by planning strategies and consistent implementation to achieve results.The District Clinic Manager position will be a full time, exempt position that reports to the Director of Operations.Supervisory Responsibilities:· Accomplishes...
-
RN Clinical
6 days ago
Los Angeles, California, United States University of Southern California (USC) Full timeAs an integral part of the interdisciplinary team, the Registered Nurse utilizes the nursing process to provide therapeutic care to patients. The Registered Nurse is accountable for the coordination of patient care and education to the patient and family in accordance with the standards, policies, and practices in a compassionate, supportive, and therapeutic...
