Sr. Director, Clinical Operations Oversight

Your Role

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The Senior Director, Clinical Operations Oversight ensures clinical and operational program integrity and compliance with state and federal regulatory standards and accreditation standards.

This position works closely with management and employees to facilitate compliance with applicable federal and state regulatory requirements.

This role will also drive the efforts to obtain and retain accreditation for Blue Shield of California.

Your Work

In this role, you will :

Direct projects, initiatives, regulatory sanctions, executive-sponsored initiatives, regulatory audits or exams, internal audits, accreditations, on-site reviews, risk assessments;

audit planning, conducting mock audits, conducting audit training, managing audit evidence preparation, assessing audit preparedness.

• Develop strategic plans, make recommendations to leadership; design / implement annual compliance plan.
• Develop strong relationships with key leaders to identify and address regulatory risks and failures. Accountable for action plans designed to fully mitigate risk(s).
• Review and analyze regulations to determine the impact on plan clinical operations and identify the need for new or revised policies, procedures, plan documents.
• Establish an annual audit work plan for ongoing review of all health-related clinical operations including behavioral health to ensure regulatory compliance standards are met and any issues found are corrected.
• Collaborate with the delegation oversight program for auditing, reporting, and monitoring delegation activities; develop and implement the audit schedule and corrective action plan process;

participate in delegation joint operational meetings.

• Design regulatory compliance training and materials; review and develop regulatory policies and procedures from compliance perspective and maintain annual review and management of policies and procedures.
• Oversee communications and reporting with the regulatory agencies such as DMHC filing submissions, regulatory reporting, and ad-hoc requests.
• Participate in the DMHC and DHCS regulatory meetings and maintain relationships with the regulatory agencies.
• Update key management staff of new or updated regulatory changes / developments of new managed care legislative initiatives on functional areas.
• Prepare and submit routine regulatory reports and analysis to include, but not limited to, Department of Health Care Services (DHCS);

Department of Managed Health Care (DMHC); the California Department of Public Health (CDPH); Centers for Medicare and Medicaid Services (CMS).

Other duties as assigned.

Your Knowledge and Experience

• Requires a Bachelor's degree, and a minimum of 12 years prior relevant experience in a managed care healthcare setting with experience in Compliance, HIPAA / Privacy, FWA and / or Regulatory Affairs operations preferred, including 6 years of management experience.
• Master's degree in relevant field preferred (e.g., MHA, MBA, MPH or similar).
• Certificate of Healthcare Compliance (CHC) preferred.
• Expert knowledge of state regulatory requirements under Department of Managed Health Care and Department of Health Care Services.
• Expert knowledge of privacy laws applicable to health plans.
• Strong analytical skills, including the ability to interpret and determine the impact of complex laws, regulations, and other documents.
• Knowledge of regulatory external audits, internal auditing and effective implementation, control, and monitoring processes.
• Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside the Health Plan.
• The ability to independently achieve objectives and resolve issues under ambiguous circumstances is a must.
• Strong decision-making, organizational, planning, and problem-solving skills, and communication skills are needed to effectively interact with staff, team members and others in a professional and tactful manner.
• Ability to supervise staff in a manner that maximizes employee performance and business results.
• Strong presentation skills with the ability to tailor presentations to a specific audience, and address and interact with large groups.

Pay Range :

The pay range for this role is : $198,000.00 to $296,890.00 for California.

Note :

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade.

Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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