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Manager, Audit & Oversight (Clinical)

CalOptima Orange, CA Full-Time
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The Manager, Clinical Audit & Oversight leads the routine oversight, monitoring and auditing of externally delegated functions to ensure compliance with state, federal, and accreditation standards.  


Position Responsibilities:

  • Hires, manages and develops direct reports. Directs work assignments, measures results and initiates personnel actions.
  • Oversees the development and maintenance of CalOptima’s audit & oversight program description that support organizational and quality improvement goals and objectives.
  • Guides auditors to the completion of external audits, including providing support onsite at delegates location.
  • Serves as a liaison with other areas and business units.
  • Researches regulations and inform delegates of CalOptima of any changes to regulatory requirements.
  • Collaborates with the director in departmental budgeting activities.
  • Monitors and tracks to completion, pre-delegation and annual delegation audits for applicable areas to ensure that delegated entities and vendors continue and can perform the delegated activities prior to delegation and in accordance with the agreement.
  • Participates in workgroups that address both clinical and non-clinical internal activities that CalOptima must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), California Department of Health Services (DHS), California Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC), and any other applicable entity.
  • Serves as the knowledge expert for clinical and quality areas.   
  • Facilitates improvement teams as assigned by the director and/or senior staff.
  • Educates the CalOptima staff and external customers on compliance/regulatory initiatives.
  • Participates in Audit & Oversight Committee meetings.
  • Other projects and duties as assigned.

  • Organize and administer a complex project plan for the achievement of organizational and audit & oversight goals and objectives.
  • Demonstrate and motivate others in effective team coordination and cooperation.
  • Communicate effectively in both written and verbal formats.
  • Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies and the general public.
  • Assist in the formulation of policies and procedures; understand and interpret policies, procedures and regulations.
  • Effectively utilize computer and appropriate software (i.e., Microsoft Office Suite applications).

Experience & Education:

  • Bachelor’s degree in a health care related field or equivalent work experience is required. Master’s degree and CPHQ certification preferred.
  • Current RN license to practice in the State of California is preferred.
  • 5+ years of relevant work experience in government or health care in a public or clinical setting preferred.
  • 2+ years of lead or supervisory level experience required.
  • Valid driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for work away from the primary office 30% of the time or more required.

Knowledge of:

  • Legislative, regulatory and quality requirements for health care service delivery to beneficiaries of the following programs: Medi-Cal, Healthy Families (HF), Medical Services for Indigents (MSI), and Medicare.
  • Clinical issues related to the successful achievement of quality improvement initiatives.
  • Principles and techniques of project management to ensure that numerous goals, objectives and detailed actions are properly identified, and their status monitored.
  • Principles and practices of managed health care, health care systems, and medical administration.

Grade:  O


Recommended skills

Health Care
Managed Care
Health Insurance
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Job ID: 14328-123119


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