Senior Manager, Clinical Compliance Delegation Oversight

L.A. Care Health Plan•Los Angeles, CA

1d•$117,509 - $188,015

About The Position

The Senior Manager, Compliance Clinical Delegation Oversight provides leadership and subject matter expertise for the delegated clinical oversight, regulatory compliance, healthcare operations, process improvement, and change management. The Senior Manager is responsible for overseeing key Clinical Delegation Oversight functions, including but not limited to clinical monitoring, delegated clinical auditing, corrective action management, delegate education, regulatory implementation, and other clinical oversight activities supporting Participating Provider Groups (PPGs), Plan Partners, Specialty Health Plans, and other delegated entities. This position ensures delegated entities meet regulatory, contractual, and accreditation requirements and maintain effective clinical quality and compliance controls. The Senior Manager will work closely with cross-functional departments responsible for Utilization Management, Care Management, Quality Improvement, Population Health, Medical Affairs, Compliance, Provider Network Management, Legal, and other operational teams to mature delegated clinical oversight practices. This position is responsible for identifying clinical compliance and operational performance risks, enhancing monitoring and auditing methodologies, implementing risk-based oversight strategies, and establishing mitigation plans that ensure compliance with federal and state regulatory requirements, contractual obligations, accreditation standards, and organizational expectations. The Senior Manager collaborates closely with executive/ senior management to establish goals that align with the company’s mission and vision. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversee the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can make high-level decisions that impact on the success of L.A. Care

Requirements

At least 6 years of healthcare experience in delegated clinical operations, compliance, monitoring and auditing, or managed care operations supporting Medicare, Medicaid, and/or commercial health plans.
Experience designing and implementing clinical programs, monitoring methodologies, or regulatory compliance initiatives within complex healthcare environments.
At least 5 years of leading, supervising and/ or managing staff.
Proven experience leading organizational change, operational process improvement, and implementation of standardized workflows, governance structures, and supporting documentation.
Experience managing clinical regulatory and compliance risks, corrective action plans, remediation activities, and enterprise regulatory readiness.
Experience collaborating with regulatory agencies and cross-functional business partners to implement regulatory requirements and improve clinical operations.
Experience leveraging technology, analytics, and reporting tools to improve operational performance, decision-making, and organizational effectiveness.
Experience leading teams, projects, initiatives, or cross-functional groups
Strong expertise developing and continuously improving risk-based delegated clinical oversight programs, including monitoring, auditing, corrective action management, delegate education, and performance improvement that drive scalable, sustainable outcomes.
Advanced knowledge of delegated clinical operations, including Utilization Management, Care Management, Population Health, and delegated medical management functions within a managed care environment.
Strong analytical and critical thinking skills with the ability to identify emerging risks, evaluate performance, and implement practical, sustainable solutions.
Demonstrated ability to build collaborative partnerships with delegated entities, regulators, auditors, executive leadership, and cross-functional stakeholders while maintaining independent oversight and driving accountability.
Advanced knowledge of CMS, DHCS, DMHC, NCQA, and other applicable regulatory requirements, with the ability to interpret, implement, and support regulatory examinations, accreditation reviews, and audit readiness activities.
Proven ability to drive team performance, foster professional development, and align staff with organizational objectives.
Skilled in leveraging technology and data solutions to enhance performance monitoring, auditing, reporting, and operational effectiveness.
Strong knowledge of managed care clinical operations across Medicare, Medicaid, and Commercial lines of business.
Demonstrated project and change management skills with the ability to lead multiple initiatives and develop standardized processes, policies, procedures, and operational tools.
Proven ability to lead, coach, mentor, and develop high-performing teams while fostering collaboration, accountability, and professional growth.
Strong proficiency developing executive-level reports and presentations using Microsoft Office applications (Excel, PowerPoint, Word) and other reporting tools.
A self-starter who thrives in fast-paced, ever-changing environments, known for innovation and adaptability.
Active, current, and unrestricted California license as a healthcare professional appropriate to the position (e.g., RN, NP, PA, Pharmacist, or other comparable clinical discipline).

Nice To Haves

Experience leading enterprise clinical operations or delegated functions across multiple delegated entities and lines of business, including accreditation, regulatory readiness, or organizational transformation initiatives.
Experience implementing Governance, Risk and Compliance (GRC), audit management, workflow automation, or enterprise reporting platforms.
Adept at presenting complex data insights clearly and concisely to support informed decision-making at the senior leadership level. Skilled in using advanced tools for data visualization, analysis, and reporting to drive strategic initiatives.
Extensive experience leading delegated clinical oversight programs within a managed care organization, including monitoring, auditing, corrective action management, and regulatory readiness.
Healthcare consulting or advisory experience supporting managed care organizations through clinical operations, delegated oversight, compliance, or organizational transformation initiatives.
Certified in Healthcare Compliance Fellow (CHC-F)
Certified HealthCare Compliance (CHC)
Certified Compliance & Ethics Professional (CCEP)
Certified Professional in Healthcare Quality (CPHQ)
Lean Six Sigma Green Belt or Master Black Belt or related certification
Project Management Professional (PMP) certification.
Project Management Professional (PMP)

Responsibilities

Lead the clinical delegation oversight program strategy, annual workplan, and operating cadence to ensure effective oversight of delegated clinical activities.
Establish standardized processes, tools, and documentation requirements for delegation monitoring, audits, reporting, and issue remediation.
Serve as a key compliance partner to clinical operations and enterprise compliance leadership on delegated oversight risks, trends, and priorities.
Implement and provide guidance to the departmental and organizational processes and policies and work with senior and/or executive management to define, prioritize, and develop projects and programs.
Responsible for overseeing and managing the budgets of their respective departments.
Manage staff and day-to-day activities in the department.
Participates in the department budgeting process.
Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s).
Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.
Mentors and develop staff, building technical and problem-solving skills across the team.
Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.
Lead the development and execution of delegated clinical oversight programs that integrate monitoring, auditing, remediation, education, and performance improvement activities to ensure compliance with regulatory, contractual, accreditation, and organizational requirements.
Direct development and monitoring of Corrective Action Plans (CAPs), including root cause analysis, timelines, deliverables, validation steps, and closure criteria.
Partner with delegated entities and internal clinical leadership to drive sustainable remediation and performance improvements.
Partner with Health Services and cross-functional stakeholders to standardize oversight methodologies, identify risks and performance trends, strengthen delegate accountability, and drive continuous improvement and regulatory readiness.
Track repeat findings and trends; implement enhanced oversight where performance indicates increased risk.
Lead cross-functional workgroups, committees, and strategic initiatives that promote enterprise alignment and support organizational objectives.
Maintain effective working relationships with delegated entities, provider organizations, and vendors; support governance meetings and performance reviews.
Collaborate with internal stakeholders to align oversight findings with operational improvements.
Monitor emerging regulatory requirements and industry best practices, leading implementation of new and revised federal, state, contractual, and accreditation requirements affecting delegated clinical operations.
Interpret and operationalize new or changing regulatory guidance impacting delegated clinical activities; communicate requirements to internal stakeholders and delegated entities.
Leverage technology and data analytics to enhance operational performance, audit management, executive reporting, and strategic decision-making.
Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Ensure adherence to organizational, contractual, regulatory, and accreditation standards relevant to the team's functions.
Establish and maintain quality assurance processes that promote regulatory compliance, operational consistency, and continuous improvement.
Develop and deliver executive-level reporting summarizing oversight activity, risk levels, findings, corrective action plan (CAP) status, and emerging trends.
Present results and recommendations to senior management.
Perform other duties as assigned.