Clinical Operations Executive

Job Summary

The Clinical Operations Executive (COE) of L.A. Care Health Plan is a senior leader focused on core operations to improve clinical outcomes for its members. This individual reports directly to the Chief Medical Officer (CMO) and is responsible for operational and administrative management of the Utilization Management (UM), Case Management (CM), and Managed Long Term Supportive Services (MLTSS) teams alongside a clinical dyad partner (Senior Medical Director II). The role extends to all lines of business including Medi-Cal, Medicare, and Commercial. This position holds profit and loss responsibility for and oversee the planning, organization, Key Performance Indicators (KPI)/Metrics, compliance, direction, staffing and development of L.A. Care's medical management functions. Additionally, the COE works closely with the Chief Operating Officer (COO) to allow for integration with claims, appeals and grievances, and our customer service center. The COE ensures regulatory compliance, provides subject matter expertise to help oversight of Participating Physician Group's (PPG) and Plan Partners' delegated functions, oversees clinical operations for direct lines of business, and interfaces with external agencies including local governing bodies. The position is further responsible for assuring all functions are operating in accordance with the organization's mission, values and strategic goals in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position works collaboratively with other members of Health Services leadership, Compliance, Information Technology, and Operations. This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Responsible for internal health plan operations in care management, utilization management, and managed long-term supportive services, among other business processes.

Assures compliance with all contracts and regulatory agencies [(e.g., Managed Risk Medical Insurance Board (MRMIB); Department of Managed Health Care (DMHC) / Department of Health Care Services (DHCS)/ Centers for Medicare and Medicaid Services (CMS) regulations; National Committee for Quality Assurance (NCQA)].

Oversees and monitors operational compliance with organizational standards, policies and procedures, and regulatory requirements for all areas of responsibility.

Assures department meets all regulatory requirements around turnaround times.

Oversees, develops and implements departmental policies and procedures as needed.

Moves the organization towards better operational performance reflected in Key Performance Indicators (KPIs)

Maintains effective communication mechanisms with various levels of the organization and with external organizations.

Identifies and implements programs that improve the provision of services to members.

Oversees the process of measuring and analyzing effectiveness of Plan Partners and delegated PPG functions, while ensuring the maintenance of positive relationships.

Duties Continued

Assures appropriate communication and coordination with CBOs and other external agencies.

Holds self and team accountable for delivering high quality work within mandated turn-around times.

Achieve consistently high ratings on regulatory reviews and audits.

 Identifies problems and develops efficient and effective solutions in a timely manner, which sharing information with key stakeholders.

Manages department within approved budget and has clear and applicable explanation for variance.

Develops and maintains a culturally sensitive work environment that promotes staff growth and education.

Establishes a plan to address productivity, operational performance, staff retention and satisfaction.

Partners with other Health Services departments to foster quality and efficiently provided health care.

Completes performance appraisals in accordance with established policies and based upon achievement of the L.A. Care mission, value, objectives and management expectations.

Maintains confidentiality in compliance with all HIPAA requirements.

Actively identifies and makes recommendations to supervisor, ideas to improve the quality effectiveness and efficiency of health services functions and organization-wide functions.

Effectively communicates CM, UM, MLTSS strategy and direction both within the organization and externally.

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.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 10 years in progressive senior operational management roles.  Including hiring, training, managing workload and performance, with teams of some scale.

At least 7 years of experience in a large health plan or delegated provider group with core UM and CM functions.

Must have experience working in a matrixed organization, with the ability to navigate for optimal results.

Experience working with government and commercial payers.

Experience interfacing with regulatory and accrediting agencies.

Experience with utilization management, case management and/or disease management programs.

Preferred: 

Experience with Medicare, Medicaid and/or Exchange products highly preferred. Experience with a delegated provider group model preferred. Experience with Medicaid or under-served and culturally diverse populations strongly preferred.

Skills

Required:

Excellent communication skills, negotiating skills, consensus building, analytic ability, planning and implementation skills. Excellent problem solving and organizational skills.

Excellent interpersonal and relationship-building skills; highly educated and mature diplomat.

Able to listen, work with diverse constituents, and find common ground.

Impeccable integrity, both in words and actions.  Must continually reinforce this characteristic.

Transparent style; open agenda; humble; enjoys feedback; welcomes debate.

Professional gravitas and credibility; comfortable dealing with senior leadership.

Preferred:

Familiarity with NCQA accreditation guidelines and standards preferred.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information