Director, Compliance Delegation Oversight Clinical Auditing and Monitoring

L.A. Care Health Plan•Los Angeles, CA

About The Position

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job SummaryThe Director, Compliance Delegation Oversight Clinical Auditing and Monitoring serves as a senior leader within the Compliance Department. The Director will manage the Clinical Delegation Oversight Unit and ensure that all audits of plan partners, Participating Provider Groups (PPGs), specialty health plans and other external first tier, downstream and related entities are audited in accordance with Compliance Department policies and procedures and guidance from all applicable regulatory agencies. This role ensures that all delegated clinical functions—are operating in full compliance with all regulatory, and contractual requirements. The Director oversees the Clinical Auditing and Monitoring Unit, centralizing all activities related to audit planning, execution, monitoring, governance, and reporting for delegated entities including PPGs, Plan Partners, specialty health plans, and other first-tier, downstream, and related First Tier Entities (FDRs). This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.

Requirements

Bachelor's Degree in Nursing or Related Field In lieu of degree, equivalent education and/or experience may be considered.
At least 7 years of experience in managed care, clinical compliance, delegation oversight, or healthcare auditing,
At least 5 years of leading staff or supervisory/management experience.
Experience developing and managing audit programs, corrective action processes, and cross-functional compliance initiatives.
In-depth knowledge of DHCS, DMHC, and CMS regulatory requirements governing delegated clinical functions..
Demonstrated expertise in clinical oversight of delegated entities, including UM, QI, Credentialing, and Case Management functions.
Knowledge of Word and Excel.
Excellent interpersonal, verbal, and written communication skills required.
Must be able to present findings to various levels of management, across all organizations.
Ensuring organizational compliance with regulatory requirements and effectively communicate to L.A. Care staff, external contacts and regulatory agencies. Build relationships with regulatory agencies to communicate compliance activities and deliverables.
Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.
Demonstrated ability to make sound and timely decisions.
Demonstrated ability to adapt to changing situations and adjust strategies accordingly
Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change..
Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
Excellent written and verbal communication, negotiation, and interpersonal skills.
Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Nice To Haves

Master's Degree in Nursing or Related Field
Registered Nurse (RN) - Active, current and unrestricted California License
Licensed Vocational Nurse (LVN) - Active, current and unrestricted California License
Certified HealthCare Compliance (CHC)

Responsibilities

Provide strategic leadership and direction for the Clinical Delegation Oversight program, ensuring alignment with enterprise compliance and quality objectives.
Develop and maintain a robust audit and monitoring framework for delegated clinical functions, ensuring consistency, accuracy, and regulatory alignment across all Lines of Business (Medi-Cal, D-SNP, LACC, and others).
Serve as the subject matter expert on clinical delegation oversight requirements, providing guidance to leadership and departments across the organization.
Partner with Regulatory Compliance, Health Services, Quality Improvement, and Provider Network Management to ensure delegated entities adhere to contractual and regulatory standards for clinical performance and compliance.
Oversee the end-to-end lifecycle of delegated clinical audits, including risk assessment, audit scheduling, tool development, fieldwork execution, and corrective action validation.
Direct the monitoring and follow-up process for CAPs (Corrective Action Plans), ensuring timely and verifiable resolution of identified deficiencies.
Oversee the preparation and presentation of audit reports, performance scorecards, and trend analyses for executive leadership and governance committees.
Foster a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals
Proactively initiate, build and maintain effective relationships and communication with both internal and external key stakeholders. Communicate with senior leadership and executives, provide reports on performance and progress towards objectives.
Develop goals, objectives and action plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews, training, and disciplinary matters for direct reports.
Develops, and manages department budget, monitors expenditures and ensures financial sustainability. Conduct strategic planning for resource management in order to meet current and future departmental and enterprise-wide goals.
Performs other duties as assigned.