Manager, Delegation Oversight Clinical Audit
4 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, 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 auditing clinical functions for 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 Centers for Medicare & Medicaid Services (CMS), California Department of Health Care Services (DHCS), and California Department of Managed Health Care (DMHC) as well as accreditation standards National Committee for Quality Assurance (NCQA).
The position ensures the clinical audit team effectively liaises with the internal stakeholders and external entities regarding audit standards, findings, corrective actions, and other issues, and serves as a resource for clinical audit related information. The position is also responsible for overseeing clinical auditors' timely and accurate documentation of audit results, holding technical calls with delegates to provide guidance, reporting to internal work groups and committees, issuing Corrective Action Plan (CAP), and conducting CAP Validations. The role aggregates, validates, and reports audit data to internal and external parties upon request.
The position works closely with senior management on clinical issues and reviews. The Manager interfaces with external agencies including other Local Initiatives, PPGs, and Health Plans. This position prepares and participates in monthly regulator calls, external audits, and being prepared to respond to inquiries. The position ensures all functions are operating in accordance with the organization's mission, values and strategic goals. This position collaborates with key stakeholders and continuously works on continuous improvement in the department. The Manager will provide an immediate and sensitive response to the needs of L.A. Care's culturally diverse membership.
The Manager remains abreast of all requirements and standards affecting L.A. Care and the entities in its Service Delivery Model. This position is responsible for revising audit tools, and ensures to reflect any legal, regulatory, contractual, accreditation, guidelines, and Plan policy updates.
This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.
DutiesManages and conducts quality control to ensure the audit work of the team meets departmental requirements and expectations, and ensures audit work accurately identifies and documents issues of potential non-compliance.
Provides ongoing guidance and leadership to ensure timely completion and accurate recording of audit results, deficiency trends, and issuance of CAP requests.
Develops and maintain written standardized operating procedures for testing and assessing compliance.
Creates new and updates audit tools based on L.A. Care policies, rules, laws, regulatory requirements, external audit findings, and other sub-regulatory guidance. Reviews and participates in operationalizing newly released or revised regulatory standards.
Develops and maintains audit related data; tracks audit results, and reports on delegates' performance.
Leads in the development and implementation of policies and procedures, and workflows that address oversight of delegates' clinical audit performance; performs ongoing assessment of process/workflow efficiency.
Performs ongoing evaluation of department's clinical audit processes to assure optimal efficiency and effectiveness. Identifies and implements clinical audit modifications to enhance departmental performance. Requests assistance from Delegation Oversight Audit Director as needed to accomplish goals. Develops and maintains effective audit-related communications between the team and key internal and external stakeholders. Leads technical calls with delegated entities regarding audit findings, root cause analysis, corrective action plans (CAP), and provides feedback on root causes and recommendations for corrective action plans.
Duties ContinuedEnsures appropriate department interface with the executive and senior management in health services. Works collaboratively with other L.A. Care departments to improve Service Quality and Clinical Quality provided to members.
Identifies performance issues or opportunities for improvement within delegated clinical operations that affect compliance. Serves as a subject matter expert to internal departments. Identifies trends from audit findings and corrective action plans. Communicates the result of the delegation oversight audit and trends to management and staff.
Prepares reports for the Delegation Oversight Committees, Quality Committees, Utilization Management Committees, Sanctions Committees, Internal Compliance Committees, etc.
Manages staff, including, but not limited to: monitoring day-to-day staff activities, monitoring of staff performance, mentoring, training, and cross training of staff, handling of questions or issues raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
Develops the training materials and programs for onboarding staff. Update training when regulatory requirements and external audit results require updates to training material.
Assists in the development of and is responsible for the implementation of departmental objectives to support organization strategies. Provides input on budget development and management, strategic planning, annual departmental goals that support L.A. Care's strategic plan, goals and mission.
Performs other duties as assigned.
Education Required
Bachelor's Degree in NursingIn lieu of degree, equivalent education and/or experience may be considered.Education Preferred
Master's Degree in Healthcare Related FieldExperience
Required:
At least 6 years of experience in auditing or oversight with a focus in areas of Utilization Management, Care Management, Quality Improvement or Behavioral Health in systematically assessing performance against set criteria based on federal and state law, regulation, contracts, accreditation standards, and against best practices, guidelines, and policies.
At least 4 years of leading staff or supervisory/management experience in a related capacity.
At least 3 years of health plan or managed care experience.
Experience with Medicaid (Medi-Cal), Medicare, and Commercial lines of business, and legal, regulatory, contractual and accreditation requirements.
Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
SkillsRequired:
Possess a high degree of flexibility to respond rapidly to meet changing goals.
Ability to work under pressure and meet deadlines, and manage several projects at one time.
Strong leadership skills with demonstrated ability to create a work environment that fosters team building and encourages a collaborative approach to achieving departmental and organizational goals.
Excellent time management and organizational skills with the ability to effectively prioritize staff assignments and make adjustments when necessary to ensure timely completion of each work product.
Excellent written and verbal communication skills.
Consistent attention to detail with exceptional issue-spotting capabilities.
Proven ability to work with staff at all levels.
Excellent interpersonal skills.
Ability to work independently with minimal supervision and within a team environment.
Ability to maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.
Advanced skills in software programs such as Excel, Power point. Knowledge of Smart Sheets.
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)
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