• AVP Delegation Oversight/Clinical Audits

    Job Locations US-CA-Aliso Viejo
    Req No.
    2018-2441
    Category
    Legal
    Type
    Regular Full-Time
  • Overview

    The Associate Vice President, Delegation Oversight and Clinical Audits reports to the General Counsel and is responsible for managing external clinical audit functions including delegation oversight audits as well as regulatory audits. Responsibilities include audit coordination as well as documentation, management and oversight of corrective action plans. The position is also responsible for development and maintenance of clinical policy. This role will work closely with the Utilization Management (UM)and Care Management (CM) teams regarding auditing functions, clinical policy and corrective action plans.

     

    This leader will monitor quality and performance metrics while also providing recommendations on operational design and efficiencies. The position will collaborate with other stakeholders and functional areas to ensure organizational alignment of clinical and operational goals.

    Responsibilities

     

    • Responsible for the oversight and management of external clinical auditing functions. This includes delegation oversight, state waiver, accrediting and regulatory audits.
    • Coordinates audit logistics and collaborates with health plan staff as well as internal staff, including UM and CM.

     

      • Prepares required documents and member specific information to be audited.
      • Serves as audit lead as well as participates in audits along with appropriate department representatives.
      • Documents any issues identified during the audit. Develops corrective actions, reviews with appropriate internal representatives and submits documents to appropriate external entities for review.
      • Collaborates with department leadership and auditors on initiatives required to remediate audit findings. Tracks completion and submission of deliverables related to corrective actions.
      • Develop and document policies related to UM and CM in collaboration with department leadership.
      • Coordinates training initiatives with department training teams and leadership to implement new processes.
    • Accountable for the achievement of identified performance and quality goals.
    • Directs and monitors direct reporting relationships including program management and quality audit staff.
    • Implements programs that align with contractual and regulatory operational requirements.
    • Supports technology development and enhancements by defining business specifications/requirements to meet accrediting, regulatory and health plan partner requirements.
    • Develops utilization management and care management policies, procedures or other job aides as needed, in collaboration with department leadership.
    • Develops and maintains collaborative relationships with internal leaders and corporate teams.
    • Coordinates proposed process changes with department leaders to ensure consistent processes for all Concerto health plan partners when feasible.
    • Leads cross-functional clinical and non-clinical meetings and other projects as needed.
    • Participates in personnel management including recruiting, hiring, goal setting, evaluations and team building.
    • Promotes a positive work environment, sets an atmosphere of open communication and feedback.
    • Performs, at a minimum, an annual assessment of operational performance across all key success metrics.
    • Other duties as assigned

    Qualifications

    • Registered Nurse with a Bachelor’s Degree. Master’s Degree preferred.
    • 5+ years Health Plan experience required.
    • Experience with MMP (or similar dual demonstration program) and/or DSNP programs required.
    • Ability to travel as needed.
    • Ability to work in a Windows based computing environment.
    • Strong interpersonal and critical-thinking skills.

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