Manager, Delegation Oversight Clinical Audit

Job Summary

The Manager, Delegation Oversight Clinical Audit is directly responsible for the oversight and monitoring functions for contracted providers, Participating Provider Groups (PPG), Plan Partners, and specialty health plans. The Delegation Oversight Clinical Audit Program activities include auditing delegated activities for compliance with State and Federal contractual compliance (CMS and DHCS) as well as accreditation standards (NCQA). The oversight activities include auditing delegated functions, performance monitoring for corrective actions, and reporting activities for internal committees as well as regulatory agencies. The position works closely with the Director, Delegation Oversight Audit on clinical issues/clinical review and interfacing with external agencies including other Local Initiatives, PPGs, and Health Plans. 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. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Responsible for the oversight and performance monitoring of the delegated PPGs and Specialty Health Plans. Reporting FWA accordingly as defined by department policy.

Assures departmental compliance with: Contract delegation agreements for all applicable regulations & standards as well as CMS, DHCS and NCQA.

Oversees and audits operational compliance with organizational standards, policies and procedures and regulatory requirements.  Ensures required standards including coordination of activities with other departments to achieve full compliance.

Assists in the development of and is responsible for the implementation of departmental objectives to support organization strategies.

Implements and enforces approved departmental policies and procedures/workflows.

Develops and maintains departmental statistical and performance reports. Facilitates data flow, analyzes, reports, design formats, interprets data and recommends alternatives/solutions internally and externally. Implements and monitors departmental performance standards.

Performs ongoing monitoring and evaluation of clinical audit to assure optimal efficiency and effectiveness. Assists in identification of and is responsible to implement clinical audit modifications to enhance departmental performance. Requests assistance from Delegation Oversight Audit Director as needed to accomplish goals. Implements, with approval, programs that improve the provision of services to members.

Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.

Assures appropriate department interface with CMO, Medical Director and Physician Advisors. Works collaboratively with other LA Care departments to improve Service Quality and Clinical Quality provided to members and to enhance the overall operational performance and efficiency of L.A. Care. Identifies performance issues or opportunities for improvement within delegated clinical operations that impact compliance. Maintains and provides input for the departmental budgets.

Duties Continued

Human Resource Management: Daily staff supervision and oversight. Develops and maintains a culturally sensitive work environment that promotes staff growth and education. Completes performance appraisals in accordance with established policies and based upon achievement of the L.A. Care mission, value, objectives and management expectations. Assures staff have access to appropriate training and educational opportunities. Recruits appropriately qualified candidates, with approval of Director. Counsels and coaches staff in consultation with Delegation Oversight Audit Director and in conjunction with HR. Participates in the hiring and termination of staff with the Delegation Oversight Audit Director and in conjunction with HR.

Responsible for oversight and adequate performance of delegated activities.

Collaborates with Utilization Management (UM), Provider Network Operations and Quality Dept.'s staff on identifying topics and agenda items for the trainings.

Maintains and audits schedules on an annual or as needed, basis.  Prepares quarterly utilization/quality reports for the Delegation Oversight Committee, Quality Committees, Sanctions Committees, and Internal Compliance Committees.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 6-8 years of experience in clinical auditing or health care with a focus in areas of Utilization Management claims.

At least 3-5 years of supervisory/management experience in a related capacity.

At least 3 years relevant health plan or managed care experience.

Audit/oversight experience.

Experience with Medi-Cal and Medicare populations and regulatory requirements.

Advanced working experience with Health Care Information Technology Systems and with advanced software programs such as Excel, PowerPoint and relational databases.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Skills

Required:
Excellent verbal and written communication skills.

Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.

Strong problem solving, planning, and organizational skills.

Demonstrates reliability and good attendance and punctuality standards.

Persuasion Skills: Ability to influence CA staff/other department staff to work together to ensure compliance, business processes and member/provider satisfaction.

Advanced skills in software programs such as Excel, Power-point and relational data bases.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information