Director, Center of Excellence and Quality Assurance

Job Summary

The Director, Center of Excellence & Quality Assurance is responsible for leading the quality, compliance, training, and continuous improvement functions that ensure L.A. Care’s Core Administrative Operations ecosystem operates with accuracy, integrity, and regulatory readiness. This role builds a disciplined quality framework that strengthens upstream and downstream controls, enhances first-pass accuracy, reduces defects, and ensures consistent, predictable outcomes across Claims Administration, Configuration, Payment Integrity, and related operational areas.

The Director oversees enterprise claims quality auditing, claims compliance oversight, issue detection and validation, corrective action planning, root-cause analysis, and enterprise reporting on quality performance. This role oversees enterprise quality for both operational claims processing and system configuration, ensuring the accuracy of benefit builds, provider reimbursement logic, system edits, pricing methodologies, and operational rules prior to deployment and ensures the organization meets federal, state, and contractual requirements by maintaining effective monitoring, quality review programs, compliance validation, and documentation standards. The Director also leads training and policy interpretation for claims-related operations, ensuring teams have the knowledge, tools, and guidance needed to maintain accuracy and adhere to changing regulatory requirements.

The Director creates a disciplined quality framework that strengthens upstream and downstream controls, enhances first-pass accuracy, reduces defects introduced through system changes, and ensures consistent execution across Core Administrative Operations service lines. The Director serves as the primary partner to operational leaders on quality and compliance matters, providing subject matter expertise on regulatory interpretation, operational risk, quality trends, and systemic improvements. This position builds a high-performing team and fosters a culture of quality, operational rigor, accountability, and continuous improvement.

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Develops strategic plans, drives change and influences critical business outcomes.

Duties

Strengthens L.A. Care’s operational quality by creating a structured, disciplined approach to auditing, compliance, and process validation.  Ensures quality is proactively managed, system and process changes are controlled, and risks are quickly identified and remediated. Through cross-functional collaboration, transparent reporting, and strong execution, that improves operational maturity, enhances accuracy, reduces rework, and supports sustainable performance across all core administrative operations.

Leads the continuous improvement and execution of the Core Administrative Operations quality audit program, including audit planning, sampling methodologies, examiner scorecards, and real-time quality monitoring, managing both examiner-level QA and configuration build validation.  Ensures quality review processes measure end-to-end claims accuracy, including benefit interpretation, provider contract application, coding, pricing, and system logic.  Oversees testing and validation of configuration changes, including benefit builds, reimbursement tables, pricing logic, clinical/non-clinical edits, and system enhancements.

Ensures robust pre-production testing (unit, peer, end-to-end, and regression testing) for all configuration changes.  Implements quality gates and validation checkpoints to prevent configuration-related defects from reaching production.  Builds and maintains quality dashboards and performance reports to provide transparency to leadership and operational teams.  Oversees validation of operational improvements, new processes, and system changes to ensure sustained accuracy and alignment with expected outcomes.

Ensures compliance with all regulatory requirements, including the Department of Managed Health Care (DMHC), the California Department of Health Care Services (DHCS), the Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and contractual obligations related to claims accuracy, turnaround times, interest payments, notices, and documentation.

Leads or supports internal and external audits, including preparation, documentation, sample reviews, responses, and corrective action plans.  Monitors regulatory changes, interprets requirements, and ensures claims operations and related departments adopt compliant practices.  Directs compliance monitoring of claims processing, Payment Integrity interventions, configuration changes, and related administrative controls.

Directs root-cause analysis of quality findings to identify systemic drivers of defects, inaccuracies, or compliance risks.  Develops corrective action plans (CAPs) with clear ownership, timelines, and measurable outcomes; monitors implementation to ensure sustainable resolution.  Provides findings to operational leaders and supports development of upstream fixes that reduce rework and strengthen control points.  Tracks and trends error patterns to proactively identify emerging risks and improvement opportunities.

Duties Continued

Establishes and maintains standard operating procedures, quality checkpoints, and control frameworks across related functions, ensuring consistency of processes, documentation, and quality standards.  Ensures all system/benefit changes have proper impact assessments, approval workflows, and documented validations prior to production deployment.  Strengthens alignment and consistency across teams by deploying standardized guidelines, documentation practices, and cross-functional workflows.

Ensures operational readiness for regulatory updates, benefit changes, system enhancements, and organizational initiatives by validating impacts on quality.  Partners with Configuration and Claims Administration to ensure system logic and operational workflows support accurate processing.

Oversees development and delivery of training programs related to claims accuracy, policy interpretation, regulatory requirements, documentation standards, and quality expectations.  Ensures training programs are aligned with audit findings, regulatory changes, and systemic improvement needs.  Maintains updated knowledge repositories, training materials, and reference documentation to support consistent operational execution.  Provides coaching to leaders and teams on quality standards, audit results, and improvement expectations.

Serves as a strategic advisor to operational, technical, and management teams on quality, compliance, and process improvement initiatives.  Collaborates with cross-functional teams to address quality issues and implement sustainable solutions.  Provides input on operational readiness for system changes, regulatory updates, and enterprise improvement work.  Represents the quality and compliance perspective in governance forums, operational reviews, and cross-functional committees.

Develops and maintains dashboards, KPIs, and scorecards to monitor quality performance, compliance adherence, and systemic risks.  Ensures leadership receives clear, actionable insights on trends, risks, and opportunities for improvement.  Monitors the effectiveness of quality interventions and updates strategies based on performance data.

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. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively. 

Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.  Identifies and actualizes enhancements to support company vision. 

Develops and maintains relationships with key stakeholders.  Leads discussions on policy operationalization and oversees key policy perspective sharing.

Leads, trains, develops, and manages a team of quality auditors, compliance analysts, training specialists, and process improvement staff.  Develops specialized configuration QA capabilities (e.g., test scripts, regression suites, system scenario modeling).  Oversees hiring, training, performance evaluations, coaching, and succession planning.  Fosters a culture of integrity, accountability, operational rigor, and continuous improvement.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 7 years of deep experience in claims quality, claims compliance, auditing, or related managed care administrative functions.

At least 5 years of experience leading, supervising and/or managing staff.

Experience in Medicaid, Medicare, and Commercial managed care lines of business.

Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.

Demonstrated experience leading enterprise audit programs or quality assurance functions.

Experience interpreting regulatory requirements and applying them to operational workflows.

Experience overseeing corrective action implementation, issue remediation, or regulatory readiness activities.

Extensive experience supporting or preparing for regulatory audits ((Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)), including corrective action planning.

Preferred:

Experience partnering with technical and configuration teams to validate system changes.

Skills

Required:

Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.

Extensive knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards (Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)/ Diagnosis Related Group (DRG)).

Strong understanding of regulatory requirements and compliance frameworks.

Advanced analytical, problem-solving, and root-cause analysis skills.

Strong project leadership and organizational skills; able to manage multiple priorities simultaneously.

Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.

Ability to work collaboratively across diverse teams and influence without direct authority.

Proficiency with Microsoft Office and data reporting tools.

Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.

Demonstrated ability to make sound and timely decisions.

Demonstrated ability to adapt to changing situations and adjust strategies accordingly

Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.

Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment

Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information