Director, Regulatory Oversight, Health Services

Date: Jun 6, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 7441 

 

Position Summary/Position

 

This position will assist in the design and implementation of a Health Services Regulatory Team to coordinate and standardize the oversight processes among the UM, BH&CM, ECM, and Pharmacy Departments to comply with DHCS, DMHC, CMS and NCQA regulations. This position will also coordinate and standardize the delegation oversight processes for those units that delegate some of their processes (UM, BH&CM and ECM). Position is also responsible for inpatient DRG auditing to ensure payment accuracy.

Major Functions (Duties and Responsibilities)

 

1. Develop a quality assurance program within health services that demonstrates each department has adequate processes to be considered “audit ready” (NCQA, CMS, DHCS and DMHC).
2. Work closely with compliance to ensure that all health services deliverables are completed timely and accurately.
3. Develop and implement a Health Services Dashboard demonstrating the level of compliance within each area and health services overall.
4. Coordinate internal mock audits with each department
5. Develop and implement an integrated file review process that reviews a variety of cases (escalated, grievances, appeals, complex etc.) to identify opportunities for improvement.
6. Develop a regulatory oversight process for ECM (Model 1’s and 2’s) in collaboration with the Director of Special Initiatives and Director of Point of Service Integrated Care.
7. Coordinate with each department Director on their workplans and identify areas in which health services can integrate their regulatory work plan.
8. Oversee that the health services department is up to date on implementing all APLs and DPLs by working closely with the compliance department and government affairs.
9. Review the current Delegation Oversight processes for each department and develop new audit and training tools to improve our oversight of our delegates. Work closely with the Delegation oversight Director to identify gaps in our delegate oversight process.
10. Ensure that each department has a method to track all interventions listed in Quality studies or work plans.
11. Identify any training opportunities for health services staff regarding regulatory compliance (Quality, Provider Services, Compliance, DO)
12. Develop and implement a Medi-Cal and Medicare IPA training on health services components such as BHCM, UM, Pharmacy, LTSS, Cal AIM (ECM and CS) in collaboration with Delegation Oversight and Provider Services. 
13. Implement a DRG auditing program to identify paid inpatient claims are paid correctly based on the appropriate DRG groupings.
14. Lead team through effective coaching and performance management.
15. Responsible for administration and oversight of the IRRs for the IEHP Health Services.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications

 

Five (5) years of experience with State and Federal requirements (DHCS, CMS, DMHC) and quality standards (NCQA) in a managed care setting. 

Education Qualifications

 

Bachelor’s degree from an accredited institution required.

Professional Certification

 

Certification in Compliance (CHC, CPHQ) is preferred, but not required. 

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement

 

Expert knowledge with State and Federal requirements and NCQA in a managed care environment. Also knowledgeable in health plan operations.

Abilities Requirement

 

Ability to establish and maintain a constructive relationship with diverse Members, management, employees, and vendors. Ability to prioritize multiple tasks, collect data, establish facts, draw valid conclusions, and implement solutions. Identify and resolve problems, effective time management and the ability to work in a fast-paced environment. Extremely organized with attention to detail and accuracy of work product. Timely turn-around of assignments is expected. 

Commitment to Team Culture

 

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

 

This is an exempt hybrid position. May include evening or weekend hours if needed to support regulatory compliance or quality projects.

Work Model Location

Hybrid

Physical Requirements

Keyboarding: Traditional - CONSTANTLY
Keyboarding: 10-Key - FREQUENTLY
Hearing: One-on-One - CONSTANTLY
Communicate: Information/ideas verbally - CONSTANTLY
Near Visual Acuity - FREQUENTLY
Sitting - CONSTANTLY
Lighting - CONSTANTLY
Regular contacts: co-workers, supervisor - CONSTANTLY
Memory - FREQUENTLY
Understand and follow direction - CONSTANTLY
Regular and reliable attendance - CONSTANTLY
Keyboarding: Touch-Screen - FREQUENTLY
Indoors - FREQUENTLY

 

Starting Salary: $153,670.40  - $195,936.00  

Pay rate will commensurate with experience

 

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 7,000 and a team of more than 2,500 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.

 


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles