Manager, Network Compliance- Clinical
SCAN Group, Long Beach, CA, United States
Manager, Network Compliance- Clinical page is loaded## Manager, Network Compliance- Clinicallocations:
Long Beach Office 3800time type:
Full timeposted on:
Posted Yesterdayjob requisition id:
JR2603Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do.Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.**The Job**Ensures that SCAN contracted network providers and other First Tier, Downstream and related entities (FDR) deliver timely, appropriate quality care and services to SCAN members consistent with the Centers for Medicare and Medicaid Services (CMS) and other state, federal and accrediting body requirements. Provides operational expertise to all delegation oversight processes and activities for clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR).**You Will**Manages and oversees day-to-day operations of the Delegation Oversight Unit clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR) Collaborates with internal departments to develop policies and procedures, and implement and monitor daily activities
Facilitates continuous quality improvement within the SCAN delegated networks by developing systems to assess, monitor and improve performance of delegated entities and other First Tier, Downstream and related entities (FDR) Serves as a resource to internal and external customers including FDRs
Maintains audit readiness, by ongoing training, competency assessment, auditing, monitoring of metrics and developing and implementing corrective action Ensures compliance with federal and state regulations and internal standards
Participates in internal and external department audits and assessments and prepares and drives the implementation of corrective action plans as indicated for such audits Supports and coordinates daily department activities by providing strong leadership
Develops and utilizes meaningful management reports to monitor staff productivity and department activities and to evaluate programs to identify potential issues and areas for improvement Attends internal and external meetings, participates in and/or facilitates SCAN committees and work groups as requested Conducts ongoing analysis; making recommendations for process improvements in work flow, organization, communication, and overall staff and program efficiency Trains staff in Delegation Oversight compliance and regulatory standards following SCAN and department policy and procedure to achieve organizational goals and outcomes
Promotes compliance with and adheres to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and accreditation bodies’ standards such as the National Committee for Quality Assurance (NCQA) as it relates to medical management and delegation oversight activities Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures
Facilitates assigned Committees and collects, analyzes and reports data and metrics Maintains staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities
Develops, implements, and maintains department documentation including policies and procedures, desktop policies and job aids, work plans, staff education materials and other documents as requested to ensure improved efficiency, productivity and outcomes Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies
Assists Director in preparation of department annual budget, annual program evaluation, and other activities as requested by management Contributes to team effort by accomplishing related results as needed
We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.Actively support the achievement of SCAN’s Vision and Goals.Other duties as assigned.**Your Qualifications**Associate's or Bachelor's Degree in NursingMust have California Registered Nurse (RN) license active and in good standing3-5 years of nursing experience2-3 years of leadership experienceComprehensive knowledge of the field's concepts and principlesPerforms complex tasks typically following established processesLeads and directs the work of other employees and has full authority for personnel decisionsPrimarily focused on administering established policies and procedures but may have some impact on departmental budgeting, strategic planning, and procedural changeAbility to foster teamwork
Decision-making skills
Problem management
Management skills
Oral and written communication skills
Ability to build collaborative relationships
Problem/situation analysis
Analytical thinking skills
Exercise good judgement* Base Pay Range: $92.400 to $133,671 annually* Work Mode: Mostly Onsite (In office 2 days per week on Tuesday/Wednesday)* An annual employee bonus program* Robust Wellness Program* Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, 2 volunteer days, and Recharge days* Excellent 401(k) Retirement Saving Plan with employer match* Robust employee recognition program* Tuition reimbursement* An opportunity to become part of a team that makes a difference to our members and our community every day!We're always looking for talented people to join our team!
Qualified applicants are encouraged to apply now!At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.#LI-JA1#LI-Hybrid**Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities***The contractor will not discharge or in any other manner discriminate
#J-18808-Ljbffr
Long Beach Office 3800time type:
Full timeposted on:
Posted Yesterdayjob requisition id:
JR2603Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do.Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.**The Job**Ensures that SCAN contracted network providers and other First Tier, Downstream and related entities (FDR) deliver timely, appropriate quality care and services to SCAN members consistent with the Centers for Medicare and Medicaid Services (CMS) and other state, federal and accrediting body requirements. Provides operational expertise to all delegation oversight processes and activities for clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR).**You Will**Manages and oversees day-to-day operations of the Delegation Oversight Unit clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR) Collaborates with internal departments to develop policies and procedures, and implement and monitor daily activities
Facilitates continuous quality improvement within the SCAN delegated networks by developing systems to assess, monitor and improve performance of delegated entities and other First Tier, Downstream and related entities (FDR) Serves as a resource to internal and external customers including FDRs
Maintains audit readiness, by ongoing training, competency assessment, auditing, monitoring of metrics and developing and implementing corrective action Ensures compliance with federal and state regulations and internal standards
Participates in internal and external department audits and assessments and prepares and drives the implementation of corrective action plans as indicated for such audits Supports and coordinates daily department activities by providing strong leadership
Develops and utilizes meaningful management reports to monitor staff productivity and department activities and to evaluate programs to identify potential issues and areas for improvement Attends internal and external meetings, participates in and/or facilitates SCAN committees and work groups as requested Conducts ongoing analysis; making recommendations for process improvements in work flow, organization, communication, and overall staff and program efficiency Trains staff in Delegation Oversight compliance and regulatory standards following SCAN and department policy and procedure to achieve organizational goals and outcomes
Promotes compliance with and adheres to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and accreditation bodies’ standards such as the National Committee for Quality Assurance (NCQA) as it relates to medical management and delegation oversight activities Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures
Facilitates assigned Committees and collects, analyzes and reports data and metrics Maintains staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities
Develops, implements, and maintains department documentation including policies and procedures, desktop policies and job aids, work plans, staff education materials and other documents as requested to ensure improved efficiency, productivity and outcomes Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies
Assists Director in preparation of department annual budget, annual program evaluation, and other activities as requested by management Contributes to team effort by accomplishing related results as needed
We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.Actively support the achievement of SCAN’s Vision and Goals.Other duties as assigned.**Your Qualifications**Associate's or Bachelor's Degree in NursingMust have California Registered Nurse (RN) license active and in good standing3-5 years of nursing experience2-3 years of leadership experienceComprehensive knowledge of the field's concepts and principlesPerforms complex tasks typically following established processesLeads and directs the work of other employees and has full authority for personnel decisionsPrimarily focused on administering established policies and procedures but may have some impact on departmental budgeting, strategic planning, and procedural changeAbility to foster teamwork
Decision-making skills
Problem management
Management skills
Oral and written communication skills
Ability to build collaborative relationships
Problem/situation analysis
Analytical thinking skills
Exercise good judgement* Base Pay Range: $92.400 to $133,671 annually* Work Mode: Mostly Onsite (In office 2 days per week on Tuesday/Wednesday)* An annual employee bonus program* Robust Wellness Program* Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, 2 volunteer days, and Recharge days* Excellent 401(k) Retirement Saving Plan with employer match* Robust employee recognition program* Tuition reimbursement* An opportunity to become part of a team that makes a difference to our members and our community every day!We're always looking for talented people to join our team!
Qualified applicants are encouraged to apply now!At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.#LI-JA1#LI-Hybrid**Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities***The contractor will not discharge or in any other manner discriminate
#J-18808-Ljbffr