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Manager, Utilization Management Quality Assurance

Job Category:  Administrative, HR, Business Professionals
Department:  Utilization Management
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8132

 

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

As a member of the Utilization Management (UM) Leadership Team, the Manager of Utilization Management Qualtiy Assurance (QA) ensures that the department's processes and activities impacting regulatory compliance meet the highest possible standards. This position will lead the design and implemention of the department's QA Plan inlcuding deploying/utilizing tools, summarizing audit findings, and overseeing the identification of training needs for UM. The position will manage the correction of regulatory audit findings, validate the implementation of corrective action plans, and provide ongoing monitoring for all regulatory audit areas. This position will lead activities aimed at improving departmental audit readiness and performance. The Manager, Utilization Management Quality Assurance will implement and develop all regulatory reports, non-clincal audit tools, minutes and communications to Senior Leadership.

Duties

Serves as the Subject Matter Expert for the UM team regarding federal, state, and local regulatory agency requirements and guidelines. Provides compliance guidance and insight into UM department's operations. Participates as a department delegate/consultant on external committees and/or departments.

 

Leads and supervises UM Quality Assurance team including, but not limited to, operational activities, audit management, deadlines, and personnel management.

 

Manages all regulatory audits for the Utilization Management Department including, but not limited to, program and data validation. Ensures timely, accurate, and complete submission of responses to the Compliance Department. Develops, maintains, and reports periodic status reports to internal Leadership Team(s) and stakeholders pursuant to activities.    

 

Designs and conducts audit readiness assessments to determine gaps in compliance; identifies opportunities for remediation and process improvement; and guides in implementation of and adherence to corrective action(s). Leads and facilitates quality assurance strategies, ensuring that the quality strategy is appropriate and effective in meeting business needs.                  

                                                          

Communicates and drives overall Quality Assurance vision, quality goals and achievements to team, as well as internal leadership on a regular basis. Aligns agency performance measures and interventions with internal stakeholders and regulators. Assists the UM department with requests for information. Ensures that they are responded to in a timely manner and that all outgoing information is detailed and tracked as appropriate.    

                                                       

Assists with the development and review of the organization's policies and procedures in relation to the implementation of new or updated regulatory requirements. Identifies the need for policies and procedures in order to ensure creation and maintenance of required documentation. Monitors and remains current on healthcare regulatory developments, legal requirements, and/or pending legislation.

 

Manages compliance incidents, assists with root-cause analyses, and implementation of corrective action and preventative measures for process and product-related non-conformances.  Creates and maintains monthly and quarterly Key Performance Indicator (KPI) Reports, ad system reports to stakeholders.  Ensure the organization's compliance with all related regulations and laws. Assist with quality training of internal team members.

 

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

 

Perform other duties as assigned

Education Required

Bachelor's Degree in Business Administration or Related Field
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Master's Degree in Business Administration or Related Field
Juris Doctor Degree or Doctor of Law Degree (J.D.)

Experience

Required:
At least 5-7 years of auditing experience in a managed care setting (preferably in Appeals, Credentialing, Grievances, Quality Improvement, UM, and etc.), including developing audit tools with at least 3-4 years of supervisory/management experience.

 

Experienced in managed healthcare product development or product management (preferably in Appeals, Credentialing, Grievances, Quality Improvement, UM, and/or Medicare+Medi-Cal product management experience).   

 

Working knowledge of DHCS, DMHC, CMS and NCQA requirements.

 

Preferred:  
Two or more years of Internal auditing experience for a health plan or healthcare system.

Work experience in health plan, physician group, or hospital administration.

At least 3 years progressive experience overseeing external regulatory audits.

Skills

Required:
Must possess a strong understanding of Medi-Cal and Medicare laws and regulations and other state programs.

 

Must have the ability to translate regulatory requirements into operational guidelines.

 

Highly developed analytical and critical thinking skills.

 

Excellent written and oral communication skills are essential. 

 

Ability to manage multiple priorities and projects and meet deadlines. 

 

Demonstrated delivering training programs and making presentations to staff and providers.

Licenses/Certifications Required

Licenses/Certifications Preferred

Certified HealthCare Compliance (CHC)

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: Medicare, Healthcare

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