Manager, Network Compliance- Clinical

SCAN Health Insurance•Long Beach, CA

1d•Hybrid

About The Position

Ensures that SCAN contracted network providers and other First Tier, Downstream and related entities (FDR) deliver timely, appropriate quality care and services to SCAN members consistent with the Centers for Medicare and Medicaid Services (CMS) and other state, federal and accrediting body requirements. Provides operational expertise to all delegation oversight processes and activities for clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR).

Requirements

Associate's or Bachelor's Degree in Nursing
Must have California Registered Nurse (RN) license active and in good standing
3-5 years of nursing experience
2-3 years of leadership experience
Comprehensive knowledge of the field's concepts and principles
Performs complex tasks typically following established processes
Leads and directs the work of other employees and has full authority for personnel decisions
Primarily focused on administering established policies and procedures but may have some impact on departmental budgeting, strategic planning, and procedural change
Ability to foster teamwork
Decision-making skills
Problem management
Management skills
Oral and written communication skills
Ability to build collaborative relationships
Problem/situation analysis
Analytical thinking skills
Exercise good judgement
A background check is required.

Nice To Haves

Curious about AI and its power to transform how we operate and serve our members.

Responsibilities

Manages and oversees day-to-day operations of the Delegation Oversight Unit clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR)
Collaborates with internal departments to develop policies and procedures, and implement and monitor daily activities
Facilitates continuous quality improvement within the SCAN delegated networks by developing systems to assess, monitor and improve performance of delegated entities and other First Tier, Downstream and related entities (FDR)
Serves as a resource to internal and external customers including FDRs
Maintains audit readiness, by ongoing training, competency assessment, auditing, monitoring of metrics and developing and implementing corrective action
Ensures compliance with federal and state regulations and internal standards
Participates in internal and external department audits and assessments and prepares and drives the implementation of corrective action plans as indicated for such audits
Supports and coordinates daily department activities by providing strong leadership
Develops and utilizes meaningful management reports to monitor staff productivity and department activities and to evaluate programs to identify potential issues and areas for improvement
Attends internal and external meetings, participates in and/or facilitates SCAN committees and work groups as requested
Conducts ongoing analysis; making recommendations for process improvements in work flow, organization, communication, and overall staff and program efficiency
Trains staff in Delegation Oversight compliance and regulatory standards following SCAN and department policy and procedure to achieve organizational goals and outcomes
Promotes compliance with and adheres to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and accreditation bodies’ standards such as the National Committee for Quality Assurance (NCQA) as it relates to medical management and delegation oversight activities
Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures
Facilitates assigned Committees and collects, analyzes and reports data and metrics
Maintains staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities
Develops, implements, and maintains department documentation including policies and procedures, desktop policies and job aids, work plans, staff education materials and other documents as requested to ensure improved efficiency, productivity and outcomes
Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies
Assists Director in preparation of department annual budget, annual program evaluation, and other activities as requested by management
Contributes to team effort by accomplishing related results as needed
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base Pay Range: $92.400 to $133,671 annually
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, 2 volunteer days, and Recharge days
Excellent 401(k) Retirement Saving Plan with employer match
Robust employee recognition program
Tuition reimbursement
An opportunity to become part of a team that makes a difference to our members and our community every day!
A competitive compensation and benefits program
An annual employee bonus program
Generous paid-time-off (PTO)
Eleven paid holidays per year
Excellent Retirement Savings program
A work-life balance
An opportunity to become part of a team that makes a difference to our members and our community every day!