Manager, Delegation Oversight Clinical Audit

Salary Range:  $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (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 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.
 

Job Summary

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.

Duties

Responsible 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 Directo