Manager, Regulatory Oversight, QAPI

Date: Sep 15, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8037 

 

Position Summary/Position

 

The Manager, Regulatory Oversight, QAPI, is responsible for the development, implementation and oversight among UM, BH&CM, ECM, and Pharmacy Departments to comply with DHCS, DMHC, and CMS regulations, including but not limited to D-SNP, Basic Health Population Health, Transitional Care Services, PBM, Care Coordination and Care Management. Under the direction of the Director of Regulatory Oversight, Health Services, this role will work closely with the UM, BH&CM, Pharmacy, Compliance and Quality departments to ensure that Health Services operations support regulatory compliance and quality outcomes.

Major Functions (Duties and Responsibilities)

 

1. Implement and maintain all initiatives related to quality and regulatory requirements.
2. Ensure multidisciplinary quality care and performance improvement activities in accordance with regulatory and quality standards as stated in the California Code of Regulations, DHCS, DMHC, CMS, and NCQA. Make significant contributions to Strategic Plan, QAPI Plan, Compliance Plan, and sets tone for quality operations and performance improvement throughout Health Services, specifically as it relates to D-SNP(Medicare), Pharmacy requirements, UM- IRRs, Basic Population Health Management and care coordination, and transitions of care .
3. Lead departments/programs in the coordination of audit information and recommends appropriate data-gathering mechanisms and procedures.
4. Develop oversight and monitoring of Health Services Departments with compliance of DHCS, DMHC, APLs/DPLs and CMS while working closely with Director of Regulatory Oversight, Compliance and Government Affairs. 
5. Develop and optimize dashboards to demonstrate multiple areas of clinical quality performance.
6. Manage quality assurance/performance improvement efforts with various leadership teams regarding performance gaps, program implementation, and performance outcomes.
7. Analyze and extract information from multiple sources. Compile statistical data into comprehensible graphs and presentations to demonstrate results and opportunities for improvement.
8. Review performance improvement data and aids in developing robust action plan to achieve key performance indicators.
9. Lead the facilitation for Health Services teams and workgroups in the development and implementation of performance improvement initiatives related to successes in reaching established goals.  
10. Conduct data analysis and audit reviews to support continuous improvement goals.
11. Facilitate and attend meetings as required and prepares requested agendas and minutes for meetings.
12. Work collaboratively with:
  a. Director of Regulatory Oversight- Health Services, to monitor Health Services effectiveness through established metrics and data
  b. Health Services Managers areas to ensure processes meet regulatory compliance with quality standards including identifying department training needs to align workflow processes with regulatory and quality compliance & audit readiness.
  c. Health Services Leadership to ensure programs are aligned with and supports inter-departmental initiatives. 
13. Lead team through effective coaching and performance management
14. Communicate quality information to departments, teams, leaders, and staff to monitor performance and evaluate changes.
15. Keep up to date with regulatory developments within and outside of the organization.
16. Oversee the coordination of regulatory compliance readiness, including California Code of Regulations, DHCS, DMHC, CMS, and NCQA. 
17. Partner with external departments, such as Compliance, Quality, and other Health Services teams,  to support healthcare regulatory compliance.
18. Facilitate, implement, and participate in quality improvement initiatives/teams.
19. Manage the development, maintenance, and revision of policies, procedures, and practices for the general compliance and operations of Health Services, as directed.
20. Develop and implement programs utilizing Lean principles.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications

 

A minimum of five (5) years of experience in a health plan and/or managed care setting in the area of integrated care, care management, care coordination, health services regulatory oversight internal and external.  A minimum of one (1) year of experience in a leadership role with experience in leading a team in Health Services required.

Preferred Experience

Education Qualifications

 

Bachelor's degree from an accredited institution required.

Preferred Education

 

Master’s degree from an accredited institution preferred.

Professional Certification

 

Certification in Compliance (CHC), CCM, CPHQ is 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 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 health plan regulations (DHCS, CMS, DMHC and NCQA). Knowledge of the Health Services Programs. Knowledge of Lean principles to problem solve and evaluate program effectiveness. Knowledge of quality assurance and performance improvement. Quality assurance. Care management and care coordination.  

Skills Requirement

 

Excellent verbal and written communication skills. Ability to use Microsoft products – Excel, Access, Power Point and Word. Skilled in public speaking. Skilled in policy reviews and editing. Excellent interpersonal skills. Ability to audit and summarize findings. Strong organizational skills.

Abilities Requirement

 

Highly organized to balance multiple projects to meet deadlines.  Must be detail-oriented. Exceptional follow-through abilities to track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed timely. Ability to manage multiple projects of varying complexity, priority levels and deadlines.  

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

 

Position may require travel and participation to external work groups/meetings.

Work Model Location

Hybrid

Physical Requirements

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

 

Starting Salary: $118,248.00  - $150,779.20  

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