The Director of Clinical Assurance is directly responsible for the planning, organizing, directing, staffing and developing L.A. Care’s Clinical Assurance Department. Responsibility includes, but is not limited to, regulatory compliance, accreditation compliance, oversight of L.A. Care’ delegated network of Plan Partners, Participating Physician Groups and Specialty Health Plans related to Health Services and managing challenging clinical situations. The Director of Clinical Assurance is also responsible to manage and oversee the preparation of the required health services responses, reports, policy and procedures to regulatory agencies. The Director is responsible to ensure all functions are operating in accordance with the organizations, mission, values and strategic goals and are provided in a manner that is responsive and sensitive to the needs of L.A. Care’s culturally diverse membership.
Responsible for the oversight functions for delegates which include, but are not limited to areas of Utilization Management, Case Management, Care Coordination, Linked & Carve Out Programs and Grievance & Appeals.
Oversight functions include auditing (pre-delegation, annual and ad hoc), performance monitoring and reporting.
Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements.
Directs measurement and analysis of delegates audits.
Assures department meets all regulatory time frames for auditing and monitoring.
Develops and implements departmental policies and procedures.
Develops and maintains departmental statistical and performance reports.
Develops, implements and monitors performance standards.
Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.
Develop and maintain departmental budgets in line with organizational goals.
Assure operational effectiveness to meet budgetary targets and optimize health care resource utilization.
Assures appropriate staff support of Utilization Management committees.
Ensuring the maintenance of positive relationships between Plan Partners, PPGs, and Vendors.
Assures completion of ongoing monitoring, audits, corrective action plan and necessary follow-up.
Facilitates communication to and involvement of Plan Partners.
Leads various committees and task forces.
Delegation Support Services:
Oversee and support providers to assist patients access tertiary level services when delegates are unable to meet the member’s clinical needs.
Human Resource Management:
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 L.A. Care mission, value, objectives and management expectations.
Assures staff have access to appropriate training and educational opportunities.
Recruits appropriately qualified candidates. Hires, counsels and terminates with approval and in conjunction with HR.
Oversees development of staff planning, including recruitment and retention.
Performs other duties as assigned.
At least 7 years relevant experience in managing and implementing Medicaid and/or Medicare programs; obtaining and sustaining National Committee for Quality Assurance (NCQA) accreditation in Health Plan/ managed care environments.
At least 5-7 years of management/supervisory experience.
Experience in healthcare focused implementations.
Experience managing projects that successfully achieve budget and timeline goals.
Current CA RN License
Bachelor’s in Nursing