22nd Century Technologies, Inc. Hiring For Manager, Delegation Oversight Clinical Audit at Los Angeles, CA  Full Time

• Responsible for the oversight and performance monitoring of the delegated PPGs and Specialty Health Plans. Reporting FWA accordingly as defined by department policy.
• Assures departmental compliance with: Contract delegation agreements for all applicable regulations & standards as well as CMS, DHCS and NCQA.
• Oversees and audits operational compliance with organizational standards, policies and procedures and regulatory requirements. Ensures that required standards including coordination of activities with other departments to achieve full compliance.
• Assists in the development of and is responsible for the implementation of departmental objectives to support organization strategies.
• Implements and enforces approved departmental policies and procedures/workflows.
• Develops and maintains departmental statistical and performance reports. Facilitates data flow, analyzes, reports, design formats, interprets data, and recommends alternatives/solutions internally and externally. Implements and monitors departmental performance standards.
• Performs ongoing monitoring and evaluation of clinical audit to assure optimal efficiency and effectiveness.
• Assists in identification of and is responsible to implement clinical audit modifications to enhance departmental performance.
• Requests assistance from Delegation Oversight Audit Director as needed to accomplish goals. Implements, with approval, programs that improve the provision of services to members.
• Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.
• Human Resource Management: Daily staff supervision and oversight. Develops and maintains a culturally sensitive work environment that promotes staff growth and education.
• Completes performance appraisals in accordance with established policies and based upon achievement of the XX Care mission, value, objectives, and management expectations.
• Assures staff have access to appropriate training and educational opportunities. Recruits appropriately qualified candidates, with approval of Director.
• Counsels and coaches’ staff in consultation with Delegation Oversight Audit Director and in conjunction with HR. Participates in the hiring and termination of staff with the Delegation Oversight Audit Director and in conjunction with HR.
• Responsible for oversight and adequate performance of delegated activities.
• Assures appropriate department interface with CMO, Medical Director and Physician Advisors. Works collaboratively with other LA Care departments to improve Service Quality and Clinical Quality provided to members and to enhance the overall operational performance and efficiency of XX Care.
• Identifies performance issues or opportunities for improvement within delegated clinical operations that impact compliance.
• Maintain and provide input for the departmental budgets.
• Collaborates with Utilization Management (UM), Provider Network Operations and Quality Dept.’s staff on identifying topics and agenda items for the trainings.
• Maintain and audit schedules on a annual or as needed, basis. Prepare quarterly utilization/quality reports for the Delegation Oversight Committee, Quality Committees, Sanctions Committees, and Internal Compliance Committees.
• Perform other duties as assigned.

Required:

• At least 6-8 years’ experience in clinical auditing or health care with a focus in areas of Utilization Management claims.
• At least 3-5 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 and Medicare populations and regulatory requirements.
• Advanced working experience with Health Care Information Technology Systems and with advanced software programs such as Excel, Power-point, and relational data bases.
• Registered Nurse (RN) – Active, current, and unrestricted California License

Qualification:

• Associate’s or bachelor’s degree in Nursing

 
22nd Century Technologies is an Equal Opportunity Employer and US Citizens & all other parties authorized to work in the US are encouraged to apply. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.