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Director, Enterprise and Network Oversight Clinical Operations

Job Category:  Management/Executive
Department:  Enterprise Performance Optimization
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  7141

 

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.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Director of Enterprise and Network Oversight Clinical Operations will lead a team that is responsible for both internal and external oversight and monitoring of delegated and non-delegated medical management and clinical operations' functions. The Director works closely with leadership to help design, execute, and monitor projects to support business goals and to accelerate the realization of L.A. Care’s clinical compliance and quality standards, Enterprise and financial goals, and strategic objectives. The Director leads efforts to implement and maintain the clinical components of EPO's integrated, proactive performance measurement and management activities, including metric-based programs, gap and risk analyses, focused audits, case file reviews, and spot investigations to ensure Plan and Network performance excellence.

 

The Director, as a subject matter expert in health care quality and delivery, including utilization management, care management, clinical operations, and initiatives and programs related to health care delivery, leads a team that will research federal and state, contractual, accreditation, and Plan-imposed requirements and standards and best practices in managed care, elicit feedback and input from key stakeholders, analyze impacts, and test all requirements applicable to the Enterprise and Network for all lines of business (Medi-Cal, Home Workers Health Plan, Personal Assistance Services Council (PASC-SEIU), L.A. Care Covered (LACC) and LACC Direct (LACC/D), and the Cal MediConnect Program (CMC) and Dual-Eligible Special Needs Plan (D-SNP).

 

Partnering across the LA Care organization, the Director will establish performance criteria and alerting metrics to systematically assess, track, and trend Enterprise and Network performance to allow for evidence-based decisions. And, the Director will work to design, implement, and monitor performance improvement plans. The Director will examine, and as necessary, strengthen process integrity and controls to manage accountabilities, mitigate risks, and protect the Plan from process waste, enforcement actions, sanctions, and other adverse outcomes, in collaboration with key stakeholders. The Director will lead all aspects of running a high-performing, efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Provides leadership to a team responsible for assurance of Plan and Network clinical performance, including proactively performing impact, gap, and risk analyses, developing and monitoring the process to track ongoing fidelity to these requirements, and collaborating to ensure all performance deficiencies are remediated.

 

Oversees efforts and ensures the effectiveness of efforts to gather, analyze, communicate, validate, and systematically track all federal and state law, contractual provisions, accreditation standards, and Plan-imposed policy applicable to the Enterprise and Provider Networks, including the Direct Network, in order to establish performance criteria for clinical functions (e.g. medical management and clinical operations).

 

Reviews member and provider-facing materials, such as policies and procedures (P&Ps), internal controls, and processes to identify gaps and opportunities for improved performance; oversees a change management process to ensure foundational materials are up-to-date. 

 

Presents performance results in visualizations and dashboards to enable Leadership to make informed decisions. Analyzes data in support of business functions, process knowledge, and systems requirements.

 

Partners with the functional business leaders to coordinate reviews and prepares for internal and regulatory audits; collaborates with providers to ensure regulatory deliverables are made timely and well; examines audit findings and responds to citied deficiencies; and, makes recommendations for corrective actions and monitors internal and external corrective action plans.

 

Develops key performance indicators, alerting requirements, and supporting metrics, to proactively inform the L.A. Care organization, senior Leadership, and relevant committees, including the Internal Compliance Committee (ICC), the Quality Oversight Committee (QOC), the Utilization Management Committee (UMC), and other bodies, of possible risks and issues with compliance, and develops remediation and corrective action plans as appropriate. 

 

Partners with internal L.A. Care departments including Compliance, Legal, Health Services, Customer Solution Center, Quality Assurance, and with Network stakeholders to ensure optimal performance of delegated and non-delegated functions. Takes proactive preventative steps to resolve issues and manage risk. Participates in governance committees and other meetings where performance issues are regularly addressed.  Responsible for leveraging and communicating all analysis to aid a diverse set of stakeholders in making informed decisions about which initiatives development and implementation.

 

Leads the Managers and their teams  monitor, and analyze remediation and corrective action plans, to help ensure optimal department quality.  

 

Directs staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

 

Perform other duties as assigned.    

Education Required

Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Juris Doctor Degree or Doctor of Law Degree (J.D.)
Master's Degree in Medicine or Related Field

Experience

Required:
A minimum of 7 years of experience in contract and/or regulatory and/or accreditation requirements analysis in managed care or other related health care industry OR healthcare experience in external regulatory or governing entity audit preparation OR in Healthcare Compliance, or other Compliance-related field.

 

At least 5-7 of  supervisory or management experience.

Skills


Required:
Demonstration of both qualitative and quantitative analytical skills.

 

Proven ability to execute large-scale, cross-functional projects while working with a diverse group of people, including external entities, physicians, support staff, coworkers and management.

 

Demonstrated ability to research issues, and supervise others' work, as the team brings about resolution either directly or with the assistance of others.

 

Strong critical thinking, analytical and problem solving skills; detail orientation.

 

Ability to navigate ambiguity and proactively adapt and develop effective plans.

 

Strong decision-making ability and demonstrated skills in guiding the decisions of others.

 

Strong written and verbal communication skills and demonstrated ability to ensure others' communications are clear and effective.

 

Strong elicitation and process documentation skills.

 

Strong organizational and communication skills to build and foster effective relationships.

 

Strategic thinker with the ability to articulate, implement strategic initiatives central to customer focus.

 

Strong leadership, team building, organizational and program/project management skills.

 

High business acumen.

 

Ability to collaborate and work crossfunctionally.

Licenses/Certifications Required

Licenses/Certifications Preferred

Certified HealthCare Compliance (CHC)
Certified in Healthcare Compliance Fellow (CHC-F)
Certified Compliance & Ethics Professional (CCEP)

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)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Clinic, Medical, Medical Research, Clinical Research, Healthcare

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