Responsible for the operations, programming and oversight of internal L.A. Care’s Care Management Department, collaboration with internal and external delegates and any operations associated with the Care Management department.
Ensures the CM department performs the following: All contracts [(i.e. Centers for Medicare and Medicaid Service (CMS), California Department of Health Care Services (DHCS)], California Department of Managed Health Care (DMHC) regulations, applicable state and federal regulations, National Committee on Quality Assurance (NCQA) CM Certification, Management Services Agreements & Other Contracts.
Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements.
Assures department meets all regulatory time frames on CM.
Develops and implements departmental policies and procedures.
Develops and maintains departmental statistical and performance reports.
Develops, implements and monitors performance standards.
Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.
Develops and maintains departmental budgets in line with organizational goals. Assures operational effectiveness to meet MCR targets and optimize health care resource utilization.
Assures appropriate staff support of Utilization Management and other relevant committees.
Supports the maintenance of positive relationships between L.A. Care and external groups.
Identifies and implements, with approval, programs that improve the provision of services to members.
Supports Clinical Assurance/Delegation Oversight in the measurement and analysis of delegated Participating Physician Group (PPG) functions.
Develops goals, objectives and actions plans for assigned staff that includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.
Undertake any additional duties as assigned, demonstrating adaptability and executive-level leadership in addressing evolving organizational needs.