Lead Regulatory Oversight Clinician (Remote)

Date: Nov 9, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8333 

 

Position Summary/Position

 

The Lead Regulatory Oversight Clinician under the direction of the Manager, Regulatory Oversight, QAPI, will lead quality improvement activities, meetings, and discussion with and between Health Service Teams, Quality Systems Teams, and other departments within the organization. The Lead Regulatory Oversight Clinician will assist management to ensure the department’s regulatory standards and LEAN project initiatives are met. The Lead Regulatory Oversight Clinician is responsible for maintaining Health Services process improvement through quality guidance/standards. Will assist with quality readiness such as preparation for Quality Improvement Compliance surveys.

Major Functions (Duties and Responsibilities)

 

1. Demonstrate advance knowledge of all processes, systems, regulations, and compliance standards. 
2. Monitor all specific departmental standards, regulatory and quality standards, and processes. 
3. Lead for process improvement procedures which consists of organizing, compiling, and reporting QI data for Health Services to identify trends, establish priorities, and recommend improvement activities.
4. Maintain a case load of up to 50% of colleagues’ work and cover TM assignments during their absence
5. Contribute to quality compliance work plan documents to ensure regular internal audits are performed to ensure readiness and identify opportunities for improvement timely.
6. Development of written summaries analyzing trends of quality audits with recommendations to Leadership.
7. Develop and maintain QA&PI compliance tools in collaboration with QAPI and CalAIM Team Members and Leadership
8. Collaborate with and provide guidance to QAPI and CalAIM Team Members and Leadership to identify audit trends and provide assistance on the development of process improvement efforts to any potential gaps in regulatory compliance, knowledge, competency, and skills
9. Collaborate with and provide guidance to QAPI and CalAIM Team Members and Leadership to implement new processes or protocols as required by the corrective action plan to meet regulatory standards as identified
10. Lead the development of departmental studies and reports that will support enhancements of Health Services activities.
11. Conduct routine research and identification of opportunities alongside Clinical Compliance Specialist, for departmental improvement to be able to make recommendations for policy and process changes to enhance compliance to IEHP and regulatory and quality requirements.
12. Recommend and create appropriate and efficient workflows, provide feedback in development of job aids and assist in validating workflows. 
13. Participate in development of new processes and ensure adherence within the team.

Experience Qualifications

 

Three (3) years of experience in care management in a health care delivery system setting. Requires a minimum of two (2) years of experience in audits and quality/compliance. Two (2) years of experience in leading others. Experience in HMO, Managed Care required. Experience with quality assurance.

Education Qualifications

 

Bachelor’s degree from an accredited institution required.

Preferred Education

 

Master’s degree from an accredited institution preferred.

Professional Certification

 

CPHQ preferred; CCM preferred

Professional Licenses

 

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

OR

Possession of an active, unrestricted, and unencumbered Clinical Social Worker (LCSW) license or Marriage and Family Therapist (LMFT) license issued by the California Board of Behavioral Sciences required. 

Drivers License Required

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

Knowledge Requirement

 

Knowledge of regulatory standards of Health Services regulatory bodies. Knowledge of Medi-Cal, CMS, DMHC and NCQA required.

Skills Requirement

 

Excellent written and verbal communication skills. Strong writing skills, time management, and understanding with interpreting/analyzing data. Read and interpret data trends.

Abilities Requirement

 

Demonstrated initiative, ability to work with others, and good professional judgment. Ability to work independently and organize time effectively.

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.

A reasonable salary expectation is between $91,000.00 and $116,022.40, based upon experience and internal equity.

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, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 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 stellar 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