CC Regulatory Performance Manager

Partnership HealthPlan of California•Fairfield, CA

About The Position

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.

Requirements

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.
Working knowledge of Medi-Cal (DHCS) program and/or NCQA Health Plan guidelines.
Current California Registered Nurse License.
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.
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.

Nice To Haves

Certifications in chosen field such as advance practice nursing or case management.

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.