Utilization Management Quality Reporting Specialist II

Job Summary

The Utilization Management (UM) Quality Reporting Specialist II is responsible for working with internal teams to support and ensure the effective implementation of regulatory and operational reporting requirements and related projects for L.A. Care’s Utilization Management Quality Assurance Team, independently and collaboratively managing assigned reporting components and project deliverables. This position ensures compliance with federal, state, and accreditation requirements.

Duties

Ensures successful completion of assigned quality projects related to regulatory and operational reporting, regulatory and accreditation audit readiness, and monitoring and oversight projects while working with UM department to support quality initiatives.

Conducts data validation to ensure integrity of regulatory and operational reports, audit universe preparation for regulatory and accreditation audits, works with management in building new reports to support operational and regulatory needs including the development of key performance indicators, conducts report mapping exercises and user acceptance testing on new reports and report enhancements, prepares reports as requested by UM Leadership team, supports data and reporting activities related to utilization management,  summarizes findings and presents results to Senior Leadership and various L.A. Care committees.

Completes projects related to the UM department’s Quality and Compliance/Regulatory/Accreditation projects and cross functional departments and teams.

Supports the UM department with routine reporting and quality activities and work plans related to quality, reporting, regulations, accreditation and compliance.     

Manages administrative activities related to reporting, compliance, and quality projects in the UM department.

Plans and organizes collaborative, cross departmental meetings to facilitate problem-solving, document issues, and validate activities or reports.

Uses reports to identify process and system gaps, informs UM Leadership Team of identified gaps for implementation of remediation actions, and verifies effectiveness of remediation efforts.

Duties Continued

Updates report job aids/desktop procedures to ensure data integrity and alignment with reporting and technical specifications.

Applies knowledge of federal and state requirements/standards to ensure compliance with reporting.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 2 years of experience in a healthcare quality or quality/compliance role.

At least 5 years of experience with regulatory and operational reports.

Experience navigating an Electronic Medical Record (EMR)system.

Experience in using analytical skills related to reporting and data processing.

Preferred:

Experience with Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) audits.

Skills

Required:

Ability to work under pressure with multiple deadlines.

Excellent verbal and written communication skills. 

Ability to develop reports and documents on an as-needed basis.

Proficient with Microsoft Excel and PowerPoint.

Knowledge of federal and state requirements and accreditation standards related to reporting.

Strong analytical and data validation skills with attention to detail.

Ability to translate data findings into actionable insights for operational and leadership stakeholders.

Strong organizational and project coordination skills with the ability to manage multiple priorities.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information