Loading...

Delegation Oversight Clinical Quality Program Manager II

Job Category:  Clinical
Department:  Delegation Oversight
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  6185

 

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 Clinical Quality Program Manager II is responsible for the development of the clinical audit and monitoring program for Delegation Oversight and L.A. Care business units. The Program Manager will develop a monitoring program based on utilization management and care management performance tasks as prescribed by regulatory, contractual, and accreditation standards. Responsible to ensure that all clinical related audit and monitoring standards and tools will be updated based on regulatory changes and accountable to ensure all current standards are captured. The role will perform quality review, monitoring data received from Clinical Assurance and will prescribe how data should be validated.  Acts as a liaison between Delegation Oversight and business units concerning all clinical activities. The Program Manager will also serve as the liaison between Delegation Oversight and Compliance, Regulatory Reporting to respond to regulatory inquiries and audits.

Duties


Continually ensures the clinical audit and monitoring data are in compliance with internal processes and regulatory requirements.

 

Builds and maintains the clinical monitoring program as a cross-functional program with business units to ensure monthly and quarterly data validation activities are implemented as prescribed.

 

Prescribe the benchmarks and thresholds of the utilization management and care management validation activities and the cadence at which these activities are to be conducted. Further, prescribes how each ingested delegate report should be reviewed and maintained to meet regulatory standards and respond to inquiries.

 

Monitors delegate deficiencies to ensure escalation and corrective action plans are implemented for both clinical audit and monitoring through CAP Validation. 

 

Ensures all new regulations and accreditation standards are updated regularly in the audit tools and monitoring standards.

 

Responds to NCQA inquiries and liaises with the L.A. Care Accreditation department to ensure the delegation oversight standards meet requirements and the Delegation Oversight program is effectively meeting NCQA standards. Conducts quarterly spot checks of the Delegation Oversight program to ensure NCQA compliance.

 

Liaises with the Compliance, Regulatory Reporting team to respond to regulatory inquiries and audits, document requests, and CAP creation, implementation, and validation.   


Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assists co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions. Actively identifies and makes recommendations to supervisor with ideas to improve the quality effectiveness and efficiency of departmental and health services functions. Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner.

 

Provide training, education and consultation as necessary to PP and PPGs. Collaborate with Clinical Audit team on identifying topics and developing agendas for the JOM's and PP visits/communication. Develop and implement procedures to assure compliance with care coordination and documentation of linked and carved out services.

 

Works with other departments as necessary to facilitate teamwork for creating and/or improving  interdepartmental processes to meet regulatory requirements.

 

Peforms other duties as assigned.

Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree in Nursing
Experience

Required:
At least 5 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management.

Skills

Required:
Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers.
 
Ability to manage and organize large volumes of data.

 

Knowledge of accreditation entities and their  requirements.

 

Excellent verbal and written communication skills and excellent interpersonal skills.

 

Good working knowledge of regulatory requirements/standards.

 

Ability to work independently.

 

Ability to solve complex issues and identify creative solutions.

 

Computer ease & literacy with Word, Excel, PowerPoint Skills.

Licenses/Certifications Required
Licensed Vocational (LVN), Registered Nurse (RN), Nurse Practitioner (NP) or Licensure in Related Field; current and unrestrited California License.
Licenses/Certifications Preferred
Required Training
Additional Information

 

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)


Nearest Major Market: Los Angeles

Job Segment: Clinic, Medical, Nursing, Registered Nurse, LVN, Healthcare