Senior Manager Compliance and Certification coordinating external audits and compliance at D - Trust GmbH in Berlin. Ensuring regulatory adherence and leading audit preparation and execution.
About the role
- Senior Manager overseeing clinical case operations at L.A. Care Health Plan, ensuring compliance and quality in health services management. Leading a team and collaborating across departments for effective case handling.
Responsibilities
- Responsible for leading clinical case operations, regulatory interpretation, and clinical decision stewardship across all grievance, appeal, and State Fair Hearing cases.
- Oversees clinical operations teams responsible for medical necessity reviews, clinical grievances and appeals, Quality of Care (QOC) referrals, clinician coordination, clinical documentation quality, and regulatory interpretation.
- Ensures collaboration with Utilization Management, the UM Medical Director, and other stakeholders to support compliant and high-quality case handling.
- Drives performance to ensure the team can lead high-level decisions that impact the success of L.A. Care.
- Manages the development, implementation, administration, and maintenance of the department's programs, policies, and procedures.
Requirements
- Bachelor's Degree in Nursing or Related Field
- At least 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory roles.
- At least 5 years of experience in leading, supervising and/or managing staff.
- Experience in Medicaid, Medicare, and Commercial managed care lines of business.
- Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations.
- Exceptional written and verbal communication skills, including executive communication.
- Proficiency with Microsoft Office, case management systems, and reporting tools.
- Registered Nurse (RN) - Active, current and unrestricted California License
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
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