Senior Delegation Oversight Specialist

Description

Central Coast Salary Range:  $84,877 - $123,072

Job Summary

This position supports the Compliance Audits, Monitoring and Oversight (AMO) Department, and Compliance Division, by coordinating full oversight of DHCS, DMHC, and CMS delegates, delegation audits, and assessing their outcomes based on regulatory requirements, contractual requirements, reviewing delegate audit related documentation, as well as assisting in writing, reviewing, and coordinating compliance action plans.

Duties & Responsibilities

• Annual evaluation with comprehensive written assessment of performance specific to State and Federal regulatory standards of the Plan, and Plan audits of downstream vendors and provider groups. Perform assessments and reassessments to include the following:
  • Examine current performance against state and federal regulatory standards, including DHCS, DMHC, and CMS.
  • Examine current performance against NCQA elements for all delegate activities.
  • Performance monitoring reports – trends and patterns.
  • Documented review of program materials; policy updates and process changes as they occur.
  • Implementation of compliance actions including documenting observed risks, development and implementation of remediation plans, and corrective action plans, as they occur or relate to delegate activities, delegation oversight audits or monitoring.
  • Reassessment of performance once a compliance action plan is implemented.
  • Ability to develop and maintain audit risk assessment tools and use industry standard tools for delegation program oversight.
• Design and implement strategies to increase delegates’ engagement in driving toward quality outcomes and cost control initiatives.
• Independently oversee coordination of delegation oversight audits for pre-delegation and annual reviews, and the collection of oversight documentation and evidence of contract adherence.
• Contribute in the implementation of audit processes to ensure compliance with federal and state statutes and regulations and program guidance.
• Contribute to the Delegation Oversight Committee by ensuring materials from stakeholders are clear, accurate, and concise. Compile meeting packets, and work with AMO management in preparation for quarterly meetings.
• Present to committee members on emerging topics or concerns related to delegates and delegation oversight.
• Participate in other plan committee meetings as needed acting as the delegation oversight expert.
• Other related projects and duties as assigned.

Primary external contacts can include the State Department of Managed Health Care, State Department of Health Care Services, Centers for Medicare & Medicaid Services, National Committee for Quality Assurance, contracted entities with Delegation Agreements, and other County Organized Health Systems and Medi-Cal plans and industry organizations such as the California Alliance of Health Plans and the Association of Health Insurance Plans.

Qualifications

Knowledge/Skills/Abilities

• Understanding of basic principles of Medi-Cal, CMS and managed care.
• Understanding of federal and state regulatory bodies and processes.
• Ability to effectively, clearly and independently document, summarize and resolve complex issues.
• Ability to analyze and interpret regulatory and contractual requirements.
• Ability to conduct and lead audits.
• Ability to develop effective audit tools.
• Ability to develop policies and procedures and compliance action plans.
• Organizational skills with ability to prioritize assignments, maintain effective administrative support systems, and meet deadlines.
• Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.
• Ability to communicate effectively and efficiently, internally and externally, with an ability to cultivate a culture of compliance norms and values.
• Comply with CenCal Health’s Code of Conduct, all regulatory and contractual requirements, CenCal Health’s policies, procedures, and internal controls.

Education & Experience

• Bachelor’s or Associate degree in a related field.
• Two-three (2-3) years’ experience in the health care field (preferably in a managed care setting).
• Must have experience researching, compiling, organizing and presenting information from various sources.
• Experience working with regulatory agencies; basic knowledge of Medi-Cal. Medicare and Knox-Keene requirements preferred.
• Experience with delegation oversight.

Salary : $84,877 - $123,072