Director ,Clinical Operations RN

The Director of Clinical Operations is a California RN licensed nurse, responsible for overseeing all aspects of the Inpatient Case Management operations. The functional responsibilities include both the clinical and technical components of the department.

• In collaboration with the Vice President of Clinical Services, plans, develops, and implements all inpatient medical management programs and processes that are consistent with the strategic, operational and budgetary goals of Regal and Lakeside Medical Groups.
• In collaboration with the Vice President of Clinical Services, Chief Medical Officer or Medical Director, identifies the need for and participates in the development and implementation of Care Management/Utilization Management policies and procedures and ensures compliance as stated below, and to promote cost-effectiveness and improved quality.
• Assists with compliance with all health plan, state and federal regulatory requirements (e.g., DMHC, CMS, SNP, NCQA where applicable), including but not limited to Pre- and Post Service Denials and inter-rater reliability surveys and assistance with certain reporting.
• Reviews and edit Regal and Lakeside Inpatient and SNF Denial process for errors and omissions to ensure network and company compliance with all applicable state and federal guidelines and laws, and all health plan directives.
• Understand all CMS and ICE UM processes/policies/procedures, especially with respect to ICE and CMS denial language and timeliness criteria.
• Through inter-departmental auditing identifies areas and staff that require additional development and/or training
• Ensures completion of Regal / Lakeside Medical Groups UM work plans and semi-annual health plan reports.
• Report compliance issues and facilitate resolution.
• Works with the Medical Management team to prepare the department for accreditation
• Works with the Chair of the UM Committee, and when necessary the Vice President of Clinical Services, Chief Medical Officer or Medical Director to coordinate activities and Utilization Management Committee meetings.
• Provides consultative services and training for internal and external UM participants and facilities.
• Is responsible for thorough and timely review and completion of monthly, quarterly and annual audits, and communication of any issues and/or trends requiring additional training and development.
• Works with Medical Management team to ensure staff development and regulatory compliance.
• Initiates and facilitates interdepartmental participation in UM-related compliance projects, as appropriate, reporting project progress to Vice President of Clinical Services Chief Medical Officer or Medical Director and other key stakeholders as needed.
• Plans, directs, assigns and oversees the day-to-day operations of Inpatient Case Management programs including report generation and regulatory compliance.
• Interview, hires, evaluates, counsels and terminates employees. Identifies opportunities for improvement and provides additional orientation and skill development on an ongoing basis.
• Ensures that all department functions are staffed appropriately and that all departmental processes are completed in a timely and accurate manner on a regular basis.
• Monitors and evaluates employee production against established benchmark standards and initiates timely corrective interventions as appropriate.
• Develops and implements individual performance goals and objectives for staff on an annual or as needed basis.
• Ensures that the Inpatient Case Management processes identify and document all health plan program requirements for optimal pay for performance initiatives.
• Develops and implements quantitative program outcomes that cost-justify the continued operation of the program on an ongoing basis.
• Develops and participates in the new employee orientation process internally, and assists Provider Relations in the orientation of contracted vendors as needed.
• Maintains regularly scheduled meetings with the department personnel including 1:1 scheduled, individual meetings with management personnel.
• Participates in internal QI Plans, Programs and Activities as directed by the Vice President of Clinical Services.
• Provides Administrative Support to the On Call staff and to all after hours service providers
• All other duties as directed by management.

Education/Requirements

• Bachelor's of Science degree in Nursing (BSN) from an accredited 4-year nursing school, Bachelor's degree in health sciences or equivalent or Master's degree preferred
• CA RN license
• Three to five (3-5) years related experience and/or training; or equivalent combination of education and experience.
• Three to five (3-5) years experience in an acute care setting is required.
• Five years experience in Case Management, or Discharge Planning required.
• Three years of management experience in Case Management required.
• Case Management certification (CCM) preferred.
• Experience with health plan audits/compliance and NCQA requirements strongly preferred.

The pay range for this position at commencement of employment is expected to be between $150,000/yr - $160,000/yr however, base pay offered may vary depending on multiple individualized factors, including market location, job related knowledge, licensure, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside

Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

• Bachelor's of Science degree in Nursing (BSN) from an accredited 4-year nursing school, Bachelor's degree in health sciences or equivalent or Master's degree preferred
• CA RN license
• Three to five (3-5) years related experience and/or training; or equivalent combination of education and experience.
• Three to five (3-5) years experience in an acute care setting is required.
• Five years experience in Case Management, or Discharge Planning required.
• Three years of management experience in Case Management required.
• Case Management certification (CCM) preferred.
• Experience with health plan audits/compliance and NCQA requirements strongly preferred.