CC Regulatory Performance Manager

Overview

To plan, manage and evaluate clinical department and/or Partnership delegate(s) performance and

compliance under DHCS and NCQA regulations. Responsibilities include annual DHCS Medical

Audits for Care Coordination, delegation oversight and monitoring activities for applicable

providers and entities, and on-going stewardship of NCQA activities to support Partnership’s continued

NCQA Accreditation.

Responsibilities

• Responsible for the prioritization, tracking and organization of care coordination policies for DHCS and NCQA auditing purposes.
• Reviews and maintains up-to-date knowledge of DHCS and NCQA regulations concerning care coordination activities and programs.
• Facilitates and completes clinical file review for internal and external DHCS and/or NCQA activities (ex: Basic Case Management, Complex Case Management, Enhanced Care Management, etc.) to ensure program goals, quality standards and department metrics are met.
• When needed, creates evidence-based tools for clinical auditing leveraging appropriate licensure and regulation requirements.
• Prepares corrective action plans, reports and presents findings to appropriate internal Partnership committees (Ex: NCQA Steering, DORS, Compliance, PAC, etc.)
• Attends regular meetings with delegate(s) and/or community agencies to provide timely performance feedback, reports, and/or improvement coaching.
• Works collaboratively with care coordination leadership to identify and implement strategies to improve quality and compliance.
• Maintains departmental library of required DHCS and NCQA documents and reports for auditing purposes
• Actively participates in organizational meetings and goals; providing input where appropriate and informing assigned team of what is learned or changed as a result of those meetings.
• Provides daily leadership, direction, resources, training, evaluation and support to staff.
• Performs leadership functions such as time card management, directing work
• activities, implementing workplace changes, conducting annual reviews, and conducting staff trainings.
• Other duties as assigned.
  
  

Qualifications

Education and Experience

Bachelors of Science in Nursing preferred; minimum five (5) years

acute care experience, two (2) years managed care experience; or

Equivalent Combination Of Education And Experience. Minimum One (1)

year prior experience in a leadership or management role.

Special Skills, Licenses and Certifications

Working knowledge of Medi-Cal (DHCS) program and/or NCQA

Health Plan guidelines. Current California Registered Nurse License.

Certifications in chosen field such as advance practice nursing or case

management. Strong knowledge of nursing standards in both inpatient

and outpatient settings. Strongly leadership, program evaluation,

auditing and management skills. Thorough knowledge of Care

Coordination, Discharge Planning, Case Management and Utilization

Review within a managed care environment. Familiarity of business

practices and protocols accessing data sets and information using

automated systems. Ability to work within an interdisciplinary

structure and function independently in a fast-paced environment while

managing multiple priorities and deadlines. Strong organizational skills

required. Computer literacy and proficiency. Valid California Driver's

License and proof of current automobile insurance compliant with

Partnership's policies are required to operate a vehicle and travel for company

business.

Performance Based Competencies

Excellent written and verbal communication skills in English.

Demonstrated experience and ability to build effective working

relationships and to represent the department effectively in order to

accomplish goals. Ability to manage multiple concurrent projects and

maintain a work pace appropriate to the workload. Ability to assist

individuals in recognizing and solving problems. Ability to supervise,

train, motivate, provide guidance to staff.

Work Environment And Physical Demands

Daily use of multi-line telephone and computer for most of the day.

Cubicle work station. Ability to use a computer keyboard. Must be able

to lift, move, or carry objects of varying size, weighing up to 10lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.
  
  

HIRING RANGE:

$136,296.78 - $177,185.82

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change