Sr. Manager, Quality Assurance and Compliance

SCAN Health Insurance•Long Beach, CA

9d•$125,400 - $181,419•Remote

About The Position

The Senior Manager of Quality Assurance and Compliance is responsible for establishing and maturing an effective quality and compliance program across Operational areas. This includes evaluating operational controls, guidelines, tools and processes for monitoring, reviewing audits meet accuracy, timeless and contractual obligations, and enhancing operational processes. This role serves as the second line of defense for the organization ensuring the organization is adhering to regulations and maintain high quality standard in operations. This function plays a vital role in ensuring the accuracy, timeliness, and efficiency of operations processing and maintaining compliance with regulatory and operational requirements.

Requirements

Bachelor’s Degree required.
5 years of related experience QA and compliance operations experience with Medicare and Medicaid.
3+ years’ management experience in healthcare environment, preferably Medicare Advantage.
8+years of progressive experience in healthcare or health plan operations.
Experience managing Quality Assurance and/or Operations Audit team.
Deep experience in operational areas such as claims, configuration, provider data, benefits, enrollment, appeals and grievances.
Proven success leading quality and compliance in a matrixed environment
Strong working knowledge of CMS and state regulations and operational implications.
Leadership - Skilled to develops others.
Problem Solving - Make critical decisions, often involving high-level risk assessment and the ability to adapt to changing circumstances.
Strategic Mindset - Formulates strategy and maps steps to achieve strategic goals.
Business Insight - In-Depth understanding of the business.
Strong verbal and written communication skills and interpersonal skills.
Strong analytical and critical thinking skills.
Detail oriented, organized and strong time management skills.
A background check is required.

Nice To Haves

Graduate or Advanced Degree or equivalent experience preferred.
Audit Certification preferred.
Experience working with AI or other machine learning tools to assist with streamlining QA processes.

Responsibilities

Responsible for developing and implementing a quality assurance program, reviewing audits meet accuracy, timeless and contractual obligations, and enhancing operational processes.
Partner with Operations leadership to design and develop an effective Quality Assurance and Compliance program gaining alignment on methodology, audit approach, KPIs, standards and issue resolution process
Manage quality and Compliance reporting. Coordinate accurate and timely submission of data, including audit readiness and documentation standards for Operations
Collaborate with operational partners to align workflows, address barriers to performance, and implement initiatives to enhance operations and member satisfaction.
Monitor and communicate performance trends track and analyze key performance indicators (KPIs). Share actionable insights and recommendations with senior leadership to inform strategic planning and resource allocation.
Establish effective governance framework to include Audit the Auditor mechanism to achieve organizational goals related to quality and compliance.
Lead a team of quality assurance and compliance professionals mentoring, fostering positive team culture, promote leadership growth, encourage innovation, and continuous learning to achieve team or individual goals
Identifying trend and areas of opportunity for process improvements and additional training
Work closely with operations leadership to review finding, develop action plans and remediate issues
Partner with operational leadership to review finding, develop corrective action plans, and remediate identified issues to the root cause ensuring a closed loop process
Monitor industry trends, regulatory changes and current events to ensure team remains informed and adapts to evolving policies and procedures.
Supervises/Manages Others (i.e. hires, performance reviews, corrective action, etc.)
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base salary range: $125,400 to $181,419 per year
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
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!