Partnership HealthPlan of California · 4 days ago
CC Regulatory Performance Manager
Fairfield, CA
Full-time
Onsite
Senior Level
$136K/yr - $177K/yr
5+ years expPartnership HealthPlan of California is seeking a CC Regulatory Performance Manager to oversee clinical department performance and compliance with DHCS and NCQA regulations. The role involves managing audits, maintaining regulatory knowledge, and providing leadership to ensure quality and compliance in care coordination activities.
Health CareInsuranceNon Profit
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
Qualification
Required
Minimum five (5) years acute care experience
Two (2) years managed care experience
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
Preferred
Bachelors of Science in Nursing
Certifications in chosen field such as advance practice nursing or case management
Company
Partnership HealthPlan of California
Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
L
Lorna Veloso
Sr. Manager of OpEx/PMO
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