Manager, Network Compliance- Clinical

Responsibilities Ensure that contracted network providers and other first tier, downstream, and related entities deliver timely, quality care and services to SCAN members consistent with CMS and other regulatory requirements. Provide operational expertise to all delegation oversight processes and activities for clinical functions including Special Needs Plans (SNP), Utilization Management (UM), Denials, and Facility Site Reviews/Medical Record Reviews (FSR/MRR). Manage day‑to‑day operations of the Delegation Oversight Unit for SNP, UM, Denials, FSR/MRR. Facilitate continuous quality improvement by developing systems to assess, monitor, and improve performance of delegated entities. Maintain audit readiness through ongoing training, competency assessment, auditing, monitoring of metrics, and implementing corrective action. Participate in internal and external audits and assessments, and drive implementation of corrective action plans. Develop and utilize meaningful management reports to monitor staff productivity and departmental activities and evaluate programs for improvement. Conduct ongoing analysis and recommend process improvements in workflow, organization, communication, and overall staff and program efficiency. Promote compliance with all regulatory and quality standards, including CMS, DMHC, DHCS, and NCQA. Develop, implement, and maintain department documentation such as policies, procedures, job aids, work plans, and staff education materials. Collaborate with internal departments to develop policies and procedures and monitor daily activities. Serve as a resource to internal and external customers, including related entities. Ensure compliance with federal and state regulations and internal standards. Support and coordinate daily department activities, providing strong leadership. Attend internal and external meetings, facilitate SCAN committees and work groups as requested. Train staff in Delegation Oversight compliance and regulatory standards following SCAN policy and procedure to achieve organizational goals and outcomes. Accomplish staff results by communicating job expectations, planning, monitoring, and appraising job results, coaching, and counseling employees, and enforcing systems, policies, and procedures. Recruit, select, orient, and train employees; maintain a safe and secure work environment; develop personal growth opportunities. Maintain professional and technical knowledge by attending workshops, reviewing professional publications, establishing networks, and participating in professional societies. Contribute to team effort by accomplishing related results as needed. Qualifications Bachelor’s degree in Nursing or related field, or equivalent experience; Master’s degree preferred. Active California Registered Nurse license. 3–5 years of compliance experience. Management experience preferred. Experience with delegation oversight. Experience working for a managed care organization such as an HMO, IPA, or Medical Group. Working knowledge of guidelines and regulations relevant to FDR compliance, including Medicare, Medi‑Cal, DMHC, SNP, NCQA, and Milliman Guidelines. Excellent written and oral communication skills, strong interpersonal, critical thinking, and analytical skills. Excellent organizational, decision‑making, and multi‑tasking skills. Demonstrated ability to work with all levels of staff within and external to the organization to achieve goals. Experience coordinating diverse groups of individuals to achieve program success. Ability to prioritize multiple competing tasks, work independently and in a team environment. Ability to work well in a fast‑paced, dynamic environment with limited supervision. Proficient in Microsoft Office. Travel 20%+ of the time; must have a valid driver’s license, automobile insurance, and reliable transportation. Benefits Base Pay Range: $106,200 to $153,705 annually. Work Mode: Mostly onsite (in‑office two days per week, Tuesday/Wednesday). Annual employee bonus program. Robust wellness program. Generous paid‑time‑off (PTO) and 11 paid holidays per year, one floating holiday, birthday off, two volunteer days, and recharge days. Excellent 401(k) retirement savings plan with employer match. Robust employee recognition program. Tuition reimbursement. Equal Opportunity Statement SCAN is proud to be an Equal Employment Opportunity and affirmative action workplace. All applicants and employees will receive consideration without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, marital status, disability, protected veteran status, or any other status protected by law. A background check is required. #J-18808-Ljbffr GRP SCAN Group