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Manager, Clinical Assurance Auditing

Job Category:  Management/Executive
Department:  Clinical Assurance
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  5575

 

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 Manager, Clinical Assurance Auditing is responsible for the team that provides clinical oversight of the Delegates and selected internal Health Services departments, which includes pre-delegation audits, annual audits and targeted audits. This position is also responsible for review and timely feedback on any corrective action plans (CAP) required as a result of adverse findings found during the audit process for both internal departments and Delegated entities. This position works closely with the Director of Clinical Assurance, Clinical Assurance Manager – Operations, Chiel Marketing Officer, Medical Directors, Compliance, Health Services Directors, Physician Advisors and/or Delegated entities to ensure regulatory requirements set by our regulators are followed and sustained. The position is further responsible to ensure all functions are operating in accordance with the organization's mission, values and strategic goals, are focused on continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership and in support of our Delegates. 

Duties

Works closely with the Clinical Assurance Director to ensure timely management and performance of audits and monitoring activities for both internal and external entities.

 

Oversight of pre-delegation audits of group's clinical units (e.g. UM prior authorization, Care Management, policies, etc.), prior to assigning delegated responsibilities.

 

Oversight of annual regulatory audits of delegated and internal entities to ensure regulatory and Plan requirements are met.

 

Oversight of targeted audits/performance monitoring activities of the delegated and internal entities to ensure that regulatory standards are maintained. 

 

Develops and maintains effective communication at various levels both with internal and external business partners. 

 

Reviews and provide feedback on corrective action plans and performance monitoring activities for both internal and external partners regarding adverse findings. 

 

Maintains and develop departmental policies to ensure regulatory requirements are met.

 

Develops and maintains departmental statistics and performance reports for internal and external partners.

 

Develops and maintains performance reports for presentation at necessary committees.

 

Responsible for assisting in identifying and implementing opportunities for process improvement within the department.

 

Provide input with development of necessary training materials for internal and external entities.

 

Maintain and provide input for department budget.

 

Oversight of direct reports, including supervision, direction, one on one meetings, coaching, time and attendance, annual performance evaluations. 

 

Ensures job aids/desktop procedures are developed and maintained for all positions responsible for auditing and performance monitoring. 

 

Maintains confidentiality in compliance with all HIPAA regulations.

 

Performs other duties as assigned.

Education Required
Bachelor's Degree in Nursing
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Master's Degree
Experience

Required:
Minimum of 6-8 years previous experience in a managed care health plan with management experience, including regulatory audits, policy writing, analyzing reports, Utilization Management and Care Management experience.

 

At least 3-5 years of supervisory/management experience in managed health care.

 

Preferred:  
Experience with Medi-Cal and those under-served and culturally diverse populations.

Audit and monitoring experience.

Skills

Required:
Excellent verbal and written communication skills.

 

Excellent interpersonal skills.

 

Good working knowledge of regulatory requirements/standards, such as NCQA, CMS, DHCS and DMHC.


Proficiency with MS Office Application, such as MS Word, Excel, and PowerPoint.

 

Ability to work independently.

 

Ability to solve complex issues and identify creative solutions.

Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Active & Current Driver's License, with a clean record and Auto Insurance Required
Licenses/Certifications Preferred
Required Training

Required: 
Registered Nurse (RN)

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)