Compliance Clinical Program Manager, Rn

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

Must reside in California - Remote position.

Health Plan of San Joaquin has an immediate opening for an experienced RN to join our Compliance team. Our Compliance Clinical Program Manager leads compliance audits with our clinical delegates. This is a key Compliance role where you will conduct audits, develop work plans, and control the monitoring processes to effectively implement work plans to ensure compliance with federal and state requirements for clinical standards and programs. We are searching for a nurse who has an in-depth knowledge of Utilization Management, Case Management, and Quality Improvement functions and related activities, as they relate to compliance.

Remote position - Must reside in California!

What You Will Be Doing:

Under general supervision, maintains assigned program(s) and oversees activities, including implementation, auditing, tracking, and reporting to ensure compliance with federal and state requirements for clinical standards and programs. Work is varied and moderately complex, and requires a moderate degree of discretion and independent judgment

Essential Functions

• Coordinates, conducts, and documents compliance oversight activities.
• Develops and manages plans to ensure activities and deliverables are completed accurately and on time; negotiates or resolves issues; escalates as needed.
• Provides guidance to internal and external stakeholders to ensure understanding and compliance with regulatory, contractual, and accreditation requirements, and organization policies and procedures.
• Works collaboratively with external and internal customers to design and implement strategies to increase engagement in driving toward quality outcomes.
• Collaborates with internal and external stakeholders to conduct routine and ad-hoc internal and external audits; identifies deficiencies that require corrective action plans.
• Coordinates or manages implementation of internal and external corrective action plans, monitoring progress and completion, coordinating interviews and document gathering; escalates as required.
• Serves as subject matter expert in the implementation and oversight of new clinical regulatory requirements.
• Analyzes and interprets regulations, data, and metrics to identify impacts, risks, opportunities, trends, variances, and other insights.
• Compiles, develops, and submits reports with written summaries and recommendations to management and stakeholders, including but not limited to operational issues, process changes and activity status
• Prepares reports and supporting documentation as required by state, NCQA and other regulators.
• Monitors key industry indicators in compliance oversight, including new products and services, through relevant subject matter resources, professional associations, industry conferences, training seminars, and other information sources.
• Supports the investigation of suspected FWA and Privacy incidents.
• Assists with the development of and maintains policies, procedures, and processes to continually improve oversight operations; provides recommendations to corresponding oversight committee.
• Assists with onboarding and training of new staff, including development of training materials.
• Participates in technical Compliance systems rollouts, enhancements, and upgrades, in alignment with key departments.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of Utilization Management, Case Management, and Quality Improvement functions and related activities, as they relate to compliance.
• In depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• In-depth knowledge of health plan functions and interactions as they relate to compliance.
• In-depth knowledge of contracting regulations and best practices.
• Knowledge of and ability to effectively apply the principles and best practices of project management, including but not limited to: project lifecycle, scope definition and management, planning and scheduling, monitoring, communication cycles, project team and risk management.
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Strong leadership skills, including but not limited to the ability to influence without authority, establish direction, build alliances and motivate others.
• Strong problem solving and analytical skills, with ability to determine key issues, develop effective action plans and implement to successful conclusion.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills, with the ability to communicate professionally to diverse individuals and groups inside and outside of HPSJ.
• Strong presentation skills, including but not limited to the ability to tailor presentations to a specific audience, and identify key messages.
• Strong knowledge of change management theory and ability to implement and manage effectively.
• Commitment to and ability to facilitate the adoption of HPSJ’s strategy, vision, mission and values.
• Advanced skills in Word, Excel, PowerPoint, and Visio.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

Preferred

• Knowledge of the compliance oversight requirements, regulations and/or processes.
• Knowledge of applicable MCS and State regulatory requirements, Medicare and Medi-Cal program and benefits.

What you Have:

Education and Experience

Required

• Graduation from an accredited nursing school; and
• At least three years clinical experience as an RN; and
• At least 3 years’ experience with Medi-Cal, Medicare, the DMHC and DHCS regulations and contract requirements; and
• Experience participating in regulatory audits; or
• Equivalent combination of education and experience.

Preferred

• Bachelor of Science in Nursing
• Bachelor’s degree in Business Administration Public Health, Health Administration or related field.
• Experience with Medi-Cal, Medicare, the DMHC and DHCS regulations and contract requirements.
• Experience with managed care operations Experience in managing vendor compliance and oversight of health-care related delegation activities.

Licenses, Certifications

Required

• Current, unrestricted California Registered Nurse license.

Preferred

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.