CC Regulatory Performance Manager at Partnership HealthPlan of California

Fairfield, California, United States -

Full Time

Start Date

Immediate

Expiry Date

16 Mar, 26

Salary

177185.82

Posted On

16 Dec, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Auditing, Leadership, Care Coordination, Case Management, Utilization Review, Regulatory Compliance, Performance Management, Quality Improvement, Nursing Standards, Medi-Cal Knowledge, NCQA Accreditation, Organizational Skills, Communication Skills, Training, Problem Solving, Team Collaboration

Industry

Insurance

Description

Overview To plan, manage and evaluate clinical department and/or Partnership delegate(s) performance andcompliance under DHCS and NCQA regulations. Responsibilities include annual DHCS MedicalAudits for Care Coordination, delegation oversight and monitoring activities for applicableproviders and entities, and on-going stewardship of NCQA activities to support Partnership’s continuedNCQA Accreditation. Responsibilities Responsible for the prioritization, tracking and organization of care coordination policiesfor DHCS and NCQA auditing purposes. Reviews and maintains up-to-date knowledge of DHCS and NCQA regulationsconcerning care coordination activities and programs. Facilitates and completes clinical file review for internal and external DHCS and/orNCQA activities (ex: Basic Case Management, Complex Case Management, EnhancedCare Management, etc.) to ensure program goals, quality standards and departmentmetrics are met. When needed, creates evidence-based tools for clinical auditing leveraging appropriatelicensure and regulation requirements. Prepares corrective action plans, reports and presents findings to appropriate internalPartnership committees (Ex: NCQA Steering, DORS, Compliance, PAC, etc.) Attends regular meetings with delegate(s) and/or community agencies to provide timelyperformance feedback, reports, and/or improvement coaching. Works collaboratively with care coordination leadership to identify and implementstrategies to improve quality and compliance. Maintains departmental library of required DHCS and NCQA documents and reports forauditing purposes Actively participates in organizational meetings and goals; providing input whereappropriate and informing assigned team of what is learned or changed as a result ofthose 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 conductingstaff trainings. Other duties as assigned. Qualifications Education and Experience Bachelors of Science in Nursing preferred; minimum five (5) yearsacute care experience, two (2) years managed care experience; orequivalent 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 NCQAHealth Plan guidelines. Current California Registered Nurse License.Certifications in chosen field such as advance practice nursing or casemanagement. Strong knowledge of nursing standards in both inpatientand outpatient settings. Strongly leadership, program evaluation,auditing and management skills. Thorough knowledge of CareCoordination, Discharge Planning, Case Management and UtilizationReview within a managed care environment. Familiarity of businesspractices and protocols accessing data sets and information usingautomated systems. Ability to work within an interdisciplinarystructure and function independently in a fast-paced environment whilemanaging multiple priorities and deadlines. Strong organizational skillsrequired. Computer literacy and proficiency. Valid California Driver'sLicense and proof of current automobile insurance compliant withPartnership's policies are required to operate a vehicle and travel for companybusiness. Performance Based Competencies Excellent written and verbal communication skills in English.Demonstrated experience and ability to build effective workingrelationships and to represent the department effectively in order toaccomplish goals. Ability to manage multiple concurrent projects andmaintain a work pace appropriate to the workload. Ability to assistindividuals 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 ableto 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

Responsibilities

The CC Regulatory Performance Manager is responsible for planning, managing, and evaluating clinical department performance and compliance with DHCS and NCQA regulations. This includes conducting audits, preparing reports, and collaborating with leadership to improve quality and compliance.