Senior Manager, Clinical and Regulatory Operations

Job Summary

The Senior Manager, Clinical and Regulatory Operations, is responsible for leading clinical case operations, regulatory interpretation, and clinical decision stewardship across all grievance, appeal, and State Fair Hearing cases. This position ensures that clinical and non-clinical case handling meets medical necessity standards, regulatory requirements, internal policy expectations, and quality-of-care obligations across all product lines, including Medi-Cal, Medicare, Marketplace, and delegated entities.

The Senior Manager oversees clinical operations teams responsible for medical necessity reviews, clinical grievances and appeals, Quality of Care (QOC) referrals, clinician coordination, clinical documentation quality, and regulatory interpretation. The role ensures strong collaboration with Utilization Management, the UM Medical Director, physician reviewers, Compliance, Member Services, Provider Network Management, claims teams, and the Center of Quality & Excellence to support compliant, timely, and high-quality case handling.

The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.  Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.

Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Duties

Oversees end-to-end clinical case handling, including clinical grievances, clinical appeals, medical necessity review coordination, and clinical case triage and ensures consistent application of evidence-based guidelines, clinical criteria, and regulatory standards in all clinical decisions. Partners with the clinical leadership to ensure clinical decision accuracy and appropriateness. Translates clinical guidelines, regulatory requirements, and service standards into operational workflows that ensure accurate, timely, and clinically sound case handling. Ensures clinical documentation is accurate, complete, defensible, and compliant with regulatory expectations.

Oversees Quality of Care (QOC) case identification, referral, coordination, and documentation ensuring timely escalation and coordination of complex or medically nuanced grievance and appeal cases.

Strengthens the clinical and regulatory integrity of Appeals & Grievances (A&G) operations by guiding staff in the application of medical necessity criteria, ensuring documentation quality, and providing expert regulatory interpretation. Interprets and applies Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and internal policy requirements related to grievance and appeal processes, ensuring operations maintain regulatory alignment. Serves as a subject-matter expert for regulatory interpretation, providing guidance to operational staff and leadership. Reviews, interprets, and implements regulatory updates that impact clinical or operational grievance and appeal workflows. Partners with Compliance and Legal to resolve regulatory inquiries related to clinical and operational case-handling requirements. Supports creation and revision of clinical and operational policies, SOPs, templates, letters, and decision-support tools.

Partners with cross-functional stakeholders to ensure proper handling of clinical and non-clinical cases. Coordinates cross-functional involvement in complex cases, including providers, delegates, plan partners, and medical directors. Supports operational teams in resolving regulatory or clinical issues that arise during case handling.

Oversees training and competency development for clinical operations staff, ensuring consistent understanding of medical necessity criteria, regulatory requirements, and decision-making standards. Identifies opportunities to enhance staff capability, accuracy, and regulatory alignment across clinical case-handling processes.

Oversees clinical case reporting and trend analysis, identifying patterns in clinical appeals, grievances, and QOC findings. Provides insights to leadership related to clinical drivers of grievances and appeals, opportunities for operational improvements, and service or quality risks.

Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.  Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team.

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.

Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

Responsible for overseeing and managing the budgets of their respective departments.

Duties Continued

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.  Ensures strong clinical judgment, regulatory understanding, and documentation discipline across the team.

Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory roles.

At least 5 years of experience in leading, supervising and/or managing staff.

Experience in Medicaid, Medicare, and Commercial managed care lines of business.

Demonstrated experience overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting.

Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations.

Experience developing and managing corrective action plans and driving sustainable remediation.

Experience collaborating with delegated entities, plan partners, or subcontracted networks.

Experience leading teams, projects, initiatives, or cross-functional groups.

Preferred:

Experience with analytic dashboards and visualization tools (Power BI, Tableau).

Skills

Required:

Proven ability to lead universe submissions, mock audits, and regulatory audit responses.

Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care.

Strong analytical, problem-solving, and critical thinking skills, including ability to translate trends into corrective actions.

Ability to design, implement, and sustain standardized processes and internal control structures.

Exceptional written and verbal communication skills, including executive communication and the ability to translate trends and other findings into actionable recommendations.

Proficiency with Microsoft Office, case management systems, and reporting tools.

Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.

Strong attention to detail and ability to manage multiple priorities and tight deadlines.

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.

Must have a deep understanding of financial principles.

Ability and exceptional knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.

Demonstrated ability to make informed decisions.

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.