Director, Financial Compliance

Job Summary

The Director of Financial Compliance leads L.A. Care’s enterprise delegated provider financial compliance, including financial solvency and claims audit programs across Medi-Cal, Dual Eligible Special Needs Plan (D-SNP), Personal Assistance Services Council-Service Employees International Union (PASC-SEIU), Medicare, and Covered California product lines.

This position directs a team responsible for financial solvency audits, claims audits, Medical Loss Ratio (MLR) data validation, directed payment oversight, and regulatory and contractual financial monitoring of Plan Partners, restricted Knox-Keene plans, delegated medical groups, capitated hospitals, and select vendors/first tier–downstream entities.

The Director establishes and maintains a risk-based, multi-line-of-business audit and monitoring framework aligned with Generally Accepted Accounting Principles (GAAP), Generally Accepted Auditing Standards (GAAS), Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Covered California, and contractual requirements, ensuring enterprise regulatory readiness and protection of the Plan’s financial integrity.

This position serves as a strategic financial compliance leader and advisor to the Chief Financial Officer (CFO), delivering executive-level reporting and proactive risk mitigation strategies. 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. Oversees operations, ensuring efficiency and effectiveness.

Duties

Direct planning, execution, and completion of the annual audit calendar covering financial solvency audits, claims compliance audits across all product lines. Develop and maintain a formal risk-based audit methodology tailored by delegate type, line of business, regulatory and contractual requirements, and overall risk assessment. Perform final review and approval of audit work papers, findings, and final reports to ensure technical accuracy and regulatory defensibility. Oversee issuance, monitoring, and escalation of Corrective Action Plans (CAPs), including formal CAP lifecycle governance, follow-up testing, and prevention of repeated findings. Conduct targeted and follow-up audits based on risk trends, financial performance, regulatory updates, or prior findings. Report material financial solvency findings to leadership.

Direct and oversee claims timeliness and accuracy audits for delegated medical groups, capitated hospitals, Plan Partners, and internal functions as applicable. Ensure compliance with DMHC, DHCS, CMS, and Covered California claims processing standards and timeliness requirements. Analyze claims payment trends, error rates, and denial patterns to identify systemic risks or operational breakdowns. Partner with internal departments to remediate identified deficiencies and monitor sustained corrective action. Report material claims compliance findings to leadership.

Oversee quarterly and annual financial analysis of delegated entities to assess solvency, liquidity, capital adequacy, and operational risk. Ensure completion and integrity of required monitoring reports, including Online Monitoring Tool (OMT), Monthly Timeliness Report (MTR), and other financial oversight tools. 

Develop early warning solvency indicators and financial risk dashboards to proactively identify delegate instability. Recommend escalation or intervention strategies where financial risk thresholds are exceeded.

Support CMS audits including Medicare Data Validation (MDVA), Organization Determination, Appeals & Grievances (ODAG), and related program audits and reporting. Oversee delegated entity data collection and validation processes, including monthly Medicare claims data submissions. Coordinate mock CMS audits with external consultants and manage resulting remediation plans. Ensure audit-ready documentation across all Medicare-related financial oversight functions.

Duties Continued

Lead subcontractor MLR reporting oversight and validation for Medi-Cal and other product lines as applicable. Validate subcontractor and downstream delegated entity data integrity and compliance with CMS and DHCS requirements. Coordinate corrective action for MLR data deficiencies and ensure defensible audit documentation. Provide executive-level analysis of MLR risk exposure and trend impacts.

Oversee compliance, reporting, and validation processes related to Directed Payments programs including Proposition 56, Proposition 35, Ground Emergency Medical Transportation (GEMT), Targeted Rate Increases (TRI), Private Hospital Directed Payments (PHDP) and Skilled Nursing Facility Workforce Quality Incentive (SNF WQIP). Ensure accurate and timely submission of required documentation to DHCS and other regulatory agencies. Monitor payment flows and maintain auditable documentation aligned with federal and state guidelines. Partner with internal departments on policy updates and regulatory changes affecting directed payment programs.

Lead focused audits, special investigations, and analytic initiatives to support enterprise financial risk management. Identify systemic internal control gaps and recommend operational enhancements.  Streamline and modernize audit processes to improve efficiency, risk targeting, and regulatory defensibility.

Develop goals, objectives and action plans for assigned staff which includes full management responsibility for the hiring, coaching, motivating, performance management, compensation review, disciplinary matters, and succession planning. Develop structured training plans to enhance team expertise in solvency analysis, claims auditing, MLR validation, directed payments, and regulatory compliance. Foster and promote a culture of transparency, accountability, and continuous improvement aligned with enterprise goals. Identify, nurture and upskill current and future leaders to enhance organizational performance and ensure a robust leadership pipeline. Manage departmental budget and resource planning to ensure timely audit calendar completion and future capacity needs. Conduct strategic planning to utilize resources to meet current and future departmental and enterprise-wide goals. Lead discussions on policy operationalization and oversees key policy perspective sharing. Identify and actualize enhancements to support company vision. Develop and maintain relationships with key stakeholders.

Prepare executive briefings and summary reports for the CFO and senior leadership clearly articulating audit results, financial risk exposure, and remediation status. Maintain collaborative working relationships with Plan Partners and delegated entities. Serve as the primary financial compliance liaison for regulatory audit coordination involving delegated financial oversight.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 8 years of managed care financial auditing experience (Medi-Cal, Medicare, and/or Covered California).

At least 5 years of financial solvency and/or delegated oversight experience.

At least 6 years of leading staff or supervisory/management experience.

Experience leading teams, projects, initiatives, or cross-functional groups.

Skills

Required:

Excellent verbal and written communication skills.

Ability to interface professionally with both internal and external stakeholders.

Ability to discuss and explain highly technical financial issues with non-financial professionals.

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

Excellent project managerial skills with the ability to motivate teams to produce quality materials within tight timeframes and simultaneously manage several projects.

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

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

Ability to make sound and timely decisions.

Ability to adapt to changing situations and adjust strategies accordingly.

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

Excellent negotiation skills.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information