Compliance Program Manager Clinical Audit & Oversight

What You Will Be Doing:

Under general supervision, maintains oversight responsibilities of assigned internal and delegated third-party entities and oversees their performance of clinical managed care operations and activities to ensure compliance with state, federal and NCQA requirements and HPSJ’s goals and objectives. Work is varied and moderately complex and requires a moderate degree of discretion and independent judgement.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

Essential Functions:

• Serve as HPSJ’s point of contact and build collaborative working relationships with assigned internal department leads and third-party entities in matters related to their contractual and regulatory obligations.
• Monitors and tracks service levels/performance for assigned internal clinical department and third-party entities.
• Conducts Readiness Assessments (Pre-Delegation or Pre-Contractual) of applicable clinical areas for third-party entities to ensure the ability to perform business activities prior to contract execution and in accordance with state, federal, NCQA and other regulatory and contractual requirements.
• Conducts internal and external audits of clinical operational functions based on regulatory and contractual requirements.
• Responsible for oversight and monitoring of clinical operational areas for internal and external delegates and vendors including, but not limited to, Utilization Management, Case Management, Behavioral Health, Grievance & Appeals, and Quality Improvement.
• Compiles dashboards and communicates oversight results timely with internal and external stakeholders.
• Reviews and analyzes reports to identify areas of risk; escalates risk areas to Manager, Director and other internal stakeholders for further action.
• Escalates prolonged or non-responsive performance issues to the following, but not limited to, Executive Team, Compliance Committee, Audit & Oversight Committee and/or Provider Contracting for further disciplinary action and/or remediation planning.
• Issues internal and external corrective action plans for non-compliance with plan policies, regulatory and contractual requirements; works collaboratively to ensure remediation of corrective action plans.
• Collaborates with Compliance and provides webinar training or written communication to internal and external delegates on applicable regulatory changes
• Leads or participates in regular or ad hoc Joint Operations Meetings (JOM) with the assigned third-party entities regularly, in addition to focused performance meetings.
• Conducts relevant training and education, as needed.
• Provide comprehensive support and serve as a backup for team members across various functions, ensuring seamless continuity of compliance program management and oversight during absences or high-demand periods.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of internal and delegation oversight process in a regulated managed care environment, including but not limited to Utilization Management, Quality Improvement, Case Management, Behavioral Health, and Grievance & Appeals.
• In-depth knowledge of State, Federal, and NCQA requirements and standards related to Medi-Cal and Medicare D-SNP Programs.
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Knowledge of and ability to effectively apply the principles and best practices of project management, including but not limited to project lifecycle, scope definition and management, planning and scheduling, monitoring, communication cycles, project team and risk management.
• Builds partnerships and works collaboratively with others to meet shared objectives.
• Strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills, with the ability to communicate professionally with diverse individuals and groups inside and outside of HPSJ.
• Strong presentation skills, including but not limited to the ability to tailor presentations to a specific audience, and identify key messages.
• Strong problem solving and analytical skills, with ability to determine key issues, develop effective action plans, including escalation, and implement to successful conclusion.
• Strong leadership skills, including but not limited to the ability to influence without authority and motivate others; ability to hold third parties accountable for performance.
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Ability to work independently and as part of a team.
• Ability to read, understand and apply complex written guidelines, instructions and other materials.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines consistently.
• Strong knowledge of change management theory and ability to implement and manage effectively.
• Commitment to and ability to facilitate the adoption of HPSJ’s strategy, vision, mission and values.
• Proven arithmetic skills.
• Advanced skills in Word, Excel, PowerPoint, and Visio.
• Proficient with MS Excel, Power BI or other dashboarding tools.
• Intermediate skills in SharePoint.
• Ability to speak, be understood, read and write in English.
• Ability to handle confidential information with appropriate discretion.

Preferred

• Experience with Medi-Cal and Medicare D-SNP managed care operations.
• Knowledge of the compliance oversight requirements, regulations and/or processes.
• Knowledge of applicable CMS and State regulatory requirements, Medicare and Medi-Cal program and benefits.

What You Have:

Education and Experience

Required

• Associate’s degree in a relevant field with a valid LVN or RN license, and at least four years of experience as a program or project manager in a healthcare environment; or
• Bachelor's Degree and at least two years of relevant experience as a program or project manager in a healthcare environment; and
• Experience in leading or participating in vendor, customer, or provider relationship management; or an equivalent combination of education and experience; or
• Equivalent combination of education and experience.

Preferred

• Master’s degree in business administration, Public Health, Health Administration or related field.
• PMP and/or LEAN/Six Sigma certification.
• Experience with Medi-Cal, Medicare D-SNP, DMHC and DHCS regulations and contract requirements.
• Experience with clinical managed care operations.
• Experience in managing vendor compliance and oversight of health-care related delegation activities.

Licenses, Certifications

Required

• Unrestricted California Vocational Nurse license; or
• Unrestricted California Registered Nurse license; or
• Equivalent clinical licensure with medical care delivery experience.

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision with choices in providers
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.