L.A. Care Health Plan · 13 hours ago
Director, Center of Excellence and Quality Assurance
1200 Building
Full-time
Onsite
Director/Executive
$135K/yr - $216K/yr
7+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income residents of Los Angeles County. The Director, Center of Excellence & Quality Assurance is responsible for leading quality, compliance, training, and continuous improvement functions to ensure operational accuracy and regulatory readiness within the organization.
FitnessGovernmentHealth Care
Responsibilities
Strengthens L.A. Care’s operational quality by creating a structured, disciplined approach to auditing, compliance, and process validation
Ensures quality is proactively managed, system and process changes are controlled, and risks are quickly identified and remediated
Through cross-functional collaboration, transparent reporting, and strong execution, that improves operational maturity, enhances accuracy, reduces rework, and supports sustainable performance across all core administrative operations
Leads the continuous improvement and execution of the Core Administrative Operations quality audit program, including audit planning, sampling methodologies, examiner scorecards, and real-time quality monitoring, managing both examiner-level QA and configuration build validation
Ensures quality review processes measure end-to-end claims accuracy, including benefit interpretation, provider contract application, coding, pricing, and system logic
Oversees testing and validation of configuration changes, including benefit builds, reimbursement tables, pricing logic, clinical/non-clinical edits, and system enhancements
Ensures robust pre-production testing (unit, peer, end-to-end, and regression testing) for all configuration changes
Implements quality gates and validation checkpoints to prevent configuration-related defects from reaching production
Builds and maintains quality dashboards and performance reports to provide transparency to leadership and operational teams
Oversees validation of operational improvements, new processes, and system changes to ensure sustained accuracy and alignment with expected outcomes
Ensures compliance with all regulatory requirements, including the Department of Managed Health Care (DMHC), the California Department of Health Care Services (DHCS), the Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and contractual obligations related to claims accuracy, turnaround times, interest payments, notices, and documentation
Leads or supports internal and external audits, including preparation, documentation, sample reviews, responses, and corrective action plans
Monitors regulatory changes, interprets requirements, and ensures claims operations and related departments adopt compliant practices
Directs compliance monitoring of claims processing, Payment Integrity interventions, configuration changes, and related administrative controls
Directs root-cause analysis of quality findings to identify systemic drivers of defects, inaccuracies, or compliance risks
Develops corrective action plans (CAPs) with clear ownership, timelines, and measurable outcomes; monitors implementation to ensure sustainable resolution
Provides findings to operational leaders and supports development of upstream fixes that reduce rework and strengthen control points
Tracks and trends error patterns to proactively identify emerging risks and improvement opportunities
Establishes and maintains standard operating procedures, quality checkpoints, and control frameworks across related functions, ensuring consistency of processes, documentation, and quality standards
Ensures all system/benefit changes have proper impact assessments, approval workflows, and documented validations prior to production deployment
Strengthens alignment and consistency across teams by deploying standardized guidelines, documentation practices, and cross-functional workflows
Ensures operational readiness for regulatory updates, benefit changes, system enhancements, and organizational initiatives by validating impacts on quality
Partners with Configuration and Claims Administration to ensure system logic and operational workflows support accurate processing
Oversees development and delivery of training programs related to claims accuracy, policy interpretation, regulatory requirements, documentation standards, and quality expectations
Ensures training programs are aligned with audit findings, regulatory changes, and systemic improvement needs
Maintains updated knowledge repositories, training materials, and reference documentation to support consistent operational execution
Provides coaching to leaders and teams on quality standards, audit results, and improvement expectations
Serves as a strategic advisor to operational, technical, and management teams on quality, compliance, and process improvement initiatives
Collaborates with cross-functional teams to address quality issues and implement sustainable solutions
Provides input on operational readiness for system changes, regulatory updates, and enterprise improvement work
Represents the quality and compliance perspective in governance forums, operational reviews, and cross-functional committees
Develops and maintains dashboards, KPIs, and scorecards to monitor quality performance, compliance adherence, and systemic risks
Ensures leadership receives clear, actionable insights on trends, risks, and opportunities for improvement
Monitors the effectiveness of quality interventions and updates strategies based on performance data
Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees
Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals
Develops, and manages budgets, utilizing resources effectively
Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals
Identifies and actualizes enhancements to support company vision
Develops and maintains relationships with key stakeholders
Leads discussions on policy operationalization and oversees key policy perspective sharing
Leads, trains, develops, and manages a team of quality auditors, compliance analysts, training specialists, and process improvement staff
Develops specialized configuration QA capabilities (e.g., test scripts, regression suites, system scenario modeling)
Oversees hiring, training, performance evaluations, coaching, and succession planning
Fosters a culture of integrity, accountability, operational rigor, and continuous improvement
Perform other duties as assigned
Qualification
Required
Bachelor's Degree
At least 7 years of deep experience in claims quality, claims compliance, auditing, or related managed care administrative functions
At least 5 years of experience leading, supervising and/or managing staff
Experience in Medicaid, Medicare, and Commercial managed care lines of business
Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing
Demonstrated experience leading enterprise audit programs or quality assurance functions
Experience interpreting regulatory requirements and applying them to operational workflows
Experience overseeing corrective action implementation, issue remediation, or regulatory readiness activities
Extensive experience supporting or preparing for regulatory audits (Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)), including corrective action planning
Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability
Extensive knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards (Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)/ Diagnosis Related Group (DRG))
Strong understanding of regulatory requirements and compliance frameworks
Advanced analytical, problem-solving, and root-cause analysis skills
Strong project leadership and organizational skills; able to manage multiple priorities simultaneously
Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation
Ability to work collaboratively across diverse teams and influence without direct authority
Proficiency with Microsoft Office and data reporting tools
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 ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations
Preferred
Master's Degree in Business Administration or Related Field
Experience partnering with technical and configuration teams to validate system changes
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
H1B Sponsorship
L.A. Care Health Plan has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (1)
2023 (1)
2021 (3)
2020 (1)
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
MarketScreener
2025-08-27
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