Senior Manager, Appeals & Grievances Regulatory Affairs
Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.
The Senior Manager, Customer Solution Center Regulatory Auditing and Reporting will be responsible for planning, coordination, facilitation, implementation, monitoring, auditing, oversight, and ongoing operational support related to all Customer Solution Center (CSC) auditing (internal/external). The Senior Manager will coordinate and collaborate with internal and external stakeholders to ensure all regulatory and contractually required measures are being followed and tracked. The Senior Manager will be directly responsible for identification of areas of improvement to assist all CSC Departments in increasing positive audit outcomes. This manager will develop, with the assistance of CSC staff and management, a successful auditing strategy with a focus on ensuring CSC staff follows all regulatory guidelines; to include internal P&Ps and Desktop Procedures alignment to regulatory requirements, auditing and monitoring of CSC staff performance against key performance indicators and metrics, recognizing trends that require individual or group retraining, provisioning of training/retraining on identified non-compliant trends or practices within CSC, and review of audit outcomes for tracking and trending purposes. This position, along with a team of Audit Readiness Analysts, is responsible for the assessment and development of an auditing readiness program to ensure compliance with regulatory requirements across all product lines (Cal MediConnect, L.A. Care Covered/ Direct, Medi-Cal, and PASC), as well as State Hearings (SFH). The audit strategy will include: review and analysis of regulatory requirements for all product lines, quality program evaluation to measure performance for key elements identified by Product Line and Audit Readiness team, barrier and trend analysis based on outcomes retrieved from the program evaluation, which is inclusive of recommended actions to remediate the potential risks identified, collaboration with key business partners, such as management and training, to ensure the Training program is relevant to the business and regulatory needs and audit readiness (Universe Validation, Timeliness, Clinical Decision and Appropriate Grievance Handling, etc.).
This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.
Responsible for ensuring compliance with applicable internal policies and procedures and external State and Federal regulations for multiple product lines (Medicaid, Medicare and Commercial). prepares materials for all audits (internal, external, mock, or regulatory), and due diligence activities; may include the collection, preparation, review, and submission of information, data, and documents to the gaming compliance officer, regulators, or auditors. Designs and implements programs, policies, and practices to be fully compliant with state and federal contracts, as well as legal and regulatory requirements; presents audit findings and all other relevant information to Senior Management, and/or the Audit Committee on an as-needed basis.
Leads compliance readiness, including but not limited to: conducting internal risk assessments, ensuring contractual and regulatory requirements are met, preparing documents for regulatory filings, reviewing submissions for quality and accuracy, providing staff education and training on compliance-related requirements, and investigating/reporting suspected cases of non-compliance.
Tracks and trends QA reviews, analyzes results from scorecards and recommend quality improvements for CSC departments, collaborates with management, training and Compliance to develop training/retraining to mitigate risks of identified non-compliant trends or practices.
Manages staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
Perform other duties as assigned.
Education RequiredBachelor's Degree in Business Administration or Health AdministrationIn lieu of degree, equivalent education and/or experience may be considered.
At a minimum of 6-8 years health care experience; five years experience in a managed care with Contact Center, A&G, compliance or a combination of experience.
At least 4-5 years of supervisory/management experiene.
Previous experience with Medi-Cal and Medicare in a managed care environment.
Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations.
Strong customer service and excellent oral and written communication skills.
Ability to trouble-shoot problem areas and recommend and develop effective system and process improvements.
Strong analytical and conflict resolution skills as well as persuasion skills.
Proficient in MS Office applications, Word, Excel, PowerPoint and Access.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.