Director, Financial Compliance

Salary Range:  $135,136.00 (Min.) - $175,676.00 (Mid.) - $216,218.00 (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.
 

Job Summary

The Director of Financial Compliance is responsible for a variety of complex areas in the Medi-Cal, D-SNP, PASC-SEIU, and Medicare benefit and process. This position directs the audit team on all aspects of health plans, capitated hospitals, and medical groups’ financial solvency audits, claims audits, quarterly/annual financial analysis, Online Monitoring Tool (OMT) and Monthly Timeliness Report (MTR) reporting. This includes audit planning, audit assignments, and ensuring completion of audit calendar and reporting. This position measures auditee compliance with appropriate Federal and State regulatory standards and prepares summary reports of findings for the Sr. Director of Financial Compliance and for distributions internally & externally. In addition, this position provides guidance based on generally accepted accounting principles, generally accepted auditing standards, Centers for Medicare and Medicaid Service (CMS), California Department of Health Care Service (DHCS), and California Department of Managed Health Care (DMHC) regulatory requirements as well as L.A. Care's service contract agreement with its provider network; conduct final review of staff audit work to ensure quality deliverables; resolve variety of complex audit issues; develop staff training plan and deliver periodic staff performance evaluations; and communicate requirements and standards to network as necessary.

 

The Director of Financial Compliance works with L.A. Care participating Plan Partners on the collaboration of financial solvency & Medi-Cal claims audit process, and overseeing the completion of these audit assignments. This position is responsible for the oversight of L.A. Care Plan Partners audits of their Medi-cal provider network.  This position regularly supports the Compliance Department on various requests for CMS and DMHC/DHCS audits.  These audits include but not limited to the CMS/Advent annual Medicare Data Validation Audit (MDVA) & Organization Determination, Appeals & Grievances (ODAG) audit.  Various detailed functions are involved in the preparation of these audits, which include but not limited to quarterly reporting of the First Team Entity Auditing & Monitoring (FTEAM) activities to the Compliance Department, overseeing the collection of monthly Medicare claims data from all the contracted Medicare Cal-MediConnect (CMC) medical groups and capitated hospitals, and involvement in the decision making of new process implementation of any CMS reporting specification & protocol updates. To prepare for CMS annual audits, Mock CMS audits with the Burchfield Group and Gorman Health Group are required to be supported including Corrective Action Plans (CAP) as necessary with CMC contracted providers.

 

The Director directs all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Manages staff to ensure completeness on the analysis of Plan Partners’ audit of their provider network. Follow-up on the corrective action plan for the non-compliant audit results. Oversight of Plan Partners’ audit of their provider network.

 

Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.  Prepares briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's  regulatory position and policy.  Develops regulatory position and policy based on research and evidence.

 

Audit Planning: Streamlines audit process to ensure audit efficiency and completion of audit calendar. Responsible for the schedule of audit fieldwork and staff assignments.

 

Financial Solvency and Claims Auditing: Manages the financial solvency and claims audit to ensure successful completion of audit calendar and enhance performance quality. Requests and follows up on CAP.  Schedules and manages the Medi-cal ER claims follow-up audit to assess the medical groups and/or capita