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Manager, Non-Clinical Network Audit

Job Category:  Administrative, HR, Business Professionals
Department:  Enterprise Performance Optimization
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8521

 

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 Enterprise Performance Optimization (EPO) Department is responsible for maintaining a centralized, integrated, proactive Enterprise Performance Optimization Program (EPOP), a Network Performance Optimization Program (NPOP), and a Network Audit Program to ensure that L.A. Care, its Provider Networks, and all of the entities in its Service Deliver Model meet the highest standards of performance excellence in serving L.A. Care members. 

The Manager for the Non-Clinical Network Audit Team is integral to the success of these efforts. The position is responsible for helping to build and administer a state-of-the art Audit Program. The role provides oversight, guidance, and direction to a team of auditors and audit coordinators as they perform audit related functions to assess the degree in which L.A. Care's network and entities, including its Participating Physician Groups (PPGs), Plan Partners, and Specialty Health Plans are compliant with federal and state law, regulation and sub-regulation, contractual provisions, accreditation standards, Plan policy, best practices, and applicable guidelines. 

The Manager is required to remain abreast of all requirements and standards impacting L.A. Care and the entities in its Service Delivery Model and to ensure audit tools are revised to reflect any legal, regulatory, contractual, accreditation, guidelines, and Plan policy updates. The position also works to integrate performance criteria across monitoring and auditing functions. And, the role helps track and trend and report on all data and information within the scope of the vertical. 

The position ensures the Audit team effectively liaises with the internal stakeholders and external entities in the Audit Program regarding audit standards, findings, corrective actions, and other issues, and to serve as a resource for all audit related information, and support providers who meet challenges in achieving compliance in specific performance areas. The position is also responsible for overseeing Auditors' timely and accurate documentation of audit results, scheduling of follow-up audits when required, reporting to internal work groups and committees, issuing Corrective Action Plan (CAP) requests, and monitoring  providers' adherence to CAP requirements. The role aggregates, validates, and reports all data and information needed to respond to internal and external audits and inquiries.

This position manages all aspects of running an efficient  team, including hiring, supervising, coaching, disciplining, and motivating direct-reports.

Duties

Leads efforts to aggregates and validates all  federal and state law, regulation, sub-regulation, contractual provisions, NCQA standards, best practices, guidelines, and Plan policy decisions and provider- and member-facing materials. Collaborates with the other verticals within EPO and with other stakeholders to integrate and track performance criteria to ensure audit and monitoring standards are streamlined and consistent. Leads change management of these standards in light of operational and/or requirements changes. 

Responsible for the oversight and performance monitoring of all EPO audit and post-audit activities.  

Provides ongoing guidance and leadership to ensure timely completion of: accurate recording of audit results, thorough analyses of delegates'  compliance status, issuance of CAP requests, and internal and external reporting.

Identifies staff training opportunities related to Clinical/UM performance, audit processes, or other topics applicable to Clinical Auditors' scope of responsibilities or work-place experience.

Collaborates with  other L.A. Care Leadership and staff, as appropriate, to develop mechanisms for enhancing audit processes, and improving EPO's ability to assist delegates in achieving full compliance with performance standards.

Participates in internal work groups and committees; presents, or delegates, reporting on the Audit Program and on audit performance of all entities in the Service Delivery Model, including tracking and trending of findings and remediation activities, including CAP implementation and validation. 

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

Creates both team and individual goals and systematically assesses team members'  progress in meeting each; provides ongoing, constructive feedback to team member concerning performance.


 

Education Required

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

Education Preferred

Master's Degree in Healthcare Related Field or Risk Management and Insurance
Doctorate Degree in Healthcare Related Field or Risk Management and Insurance

Experience

Required:
At least 5-7 years experience in auditing or oversight experience in systematically assessing performance against set criteria based on federal and state law, regulation, sub-regulation, contracts, accreditation standards, and against best practices, guidelines, and policies.

At least 3-4 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, Medicare, and Commercial lines of business  and legal, regulatory, contractual and accreditation requirements.
 

Skills

Required:
Strong leadership skills with demonstrated ability to create a work environment that fosters team building and encourages a collaborative approach to achieving departmental and organizational goals.

Excellent time management and organizational skills with the ability to effectively prioritize staff assignments and make adjustments when necessary to ensure timely completion of each work product.

Superior written and verbal communication skills.

Consistent attention to detail with exceptional issue-spotting capabilities. 

Proven ability to work with staff at all levels.

Excellent interpersonal skills.

Demonstrated critical thinking and problem solving skills.

Ability to work independently with minimal supervision and within a team environment.

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

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

Licenses/Certifications Required

Licenses/Certifications Preferred

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: Clinical Research, Medical Research, Risk Management, Medicare, Audit, Healthcare, Finance

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