Manager, Enterprise and Network Oversight Clinical Operations

Job Summary

The Manager of Enterprise and Network Oversight Clinical Operations is an integral part of ensuring the success of the Enterprise Performance Optimization Program (Enterprise POP) and the Network Performance Optimization Program (Network POP). The Manager will support internal and external oversight and monitoring of delegated and non-delegated medical management and clinical operations' functions. This position is responsible for helping execute and monitor projects, strategic plans, and programs designed to achieve the Department's goals and L.A. Care's clinical compliance and quality standards. Within an assigned scope and projects, the Manager helps lead initiatives that optimize Enterprise and Network clinical operations performance. The Manager helps lead 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 Manager must maintain subject matter expertise in health care quality and delivery, including utilization management, care management, clinical operations, and initiatives and programs related to health care delivery. This position manages a team that will aggregate federal, state, contractual, accreditation, and Plan-imposed requirements and best practices in managed care applicable to the Enterprise and L.A. Care's Plan Partners and Provider Network for all lines of business (Medi-Cal, 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)).  In collaboration with key stakeholders, this position generates performance intelligence through case file reviews and routine and ad hoc oversight and monitoring activities track, trend, analyze, and report results to enable leadership to make evidence-based decisions to remediate extant deficiencies and engage in process improvement to achieve optimal internal and external clinical operations performance.

Specific to an assigned scope, this position manages a team to establish and oversee the development and maintenance of Key Performance Indicators (KPIs or Metrics) to systematically assess, track, and trend internal L.A. Care performance and external delegate performance.  This position is responsible for ensuring that remediation planning is both satisfactory and implemented for all detected issues, in collaboration with internal units and providers.  This position manages a clinical team as they 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. Manages all aspects of running an efficient clinical team, including hiring, supervising, coaching, training, disciplining, and motivating direct and indirect staff 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.

Identify and actively engage a complete group of stakeholders to assure that related fiscal and operational impacts, and risk and liability-producing factors attendant to the implementation of requirements or policy are properly considered and adjudicated by the right parties. As rule-making evolves, this position  is responsible for keeping abreast of such changes, and partnering with stakeholders to ensure cross-functional impacts are accounted for and that all policy-making and other artifacts demonstrating the implementation of said rules are documented.

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

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
Minimum of 6-8 years of experience in risk management and/or contract and/or regulatory and/or accreditation requirements analysis related to clinical operations functions, medical management (utilization management, care/case management) in managed care or other related health care industry.

At least 3-5 years of supervisory/management experience.

Minimum of 5 years of experience in Healthcare Compliance, Risk Management, Legal, or related field, in a complex and high-demand business setting.

Skills

Required:
Demonstration of both qualitative and quantitative analytical skills.

Ability to perform Case file reviews to manage clinical operations and medical management functions.

Proven ability to work with a diverse group of people, including external entities, physicians, support staff, coworkers and management.

Demonstrated ability to research clinical issues and bring about resolution either directly or with the assistance of others.

Knowledge of Utilization Management, Case Management activities, and other clinical operations and public health management activities.

Demonstrated critical thinking and problem solving skills.

Strong written and verbal communication skills.

Strong elicitation and process documentation skills.

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

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

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information