Job Description

Position Summary:

The CQM Supervisor oversees non-clinical auditors in the Clinical Quality Management (CQM) department, ensuring regulatory compliance and the quality of processes in daily Non-Clinical Utilization Management (UM) activities, under the direction of a manager. This Supervisor is responsible for conducting live audits of UM case files, assigning drivers and presenters, and ensuring their performance is appropriate. The role also involves monitoring UM system controls and processes, specifically those that do not require clinical decisions. A solid understanding of comprehensive regulations, UM policies and procedures, the UM system, UM auditing, and quality improvement is essential for this position.

Essential Duties and Responsibilities:

- Familiarity with Non-Clinical UM regulations, processes, and systems.

- Ability to assign workloads effectively while managing staff.

- Proficient in presenting case files and conducting interviews regarding non-clinical questions.

- Skilled in designing audit tools to monitor Non-Clinical UM processes completed by non-clinical staff.

- Strong communication skills for effective interaction with internal clients and external customers.

- Capable of training employees using Policies & Procedures (P&Ps) and audit tools.

- Provide constructive feedback and exhibit strong active communication skills.

- Summarize quality monitoring findings, analyze root causes, and propose quality improvement plans.

- Suggest and design focused audits that help improve compliance in Non-Clinical UM processes.

- Request decision support for creating and enhancing Non-Clinical UM monitoring reports based on changes to UM P&Ps.

- Ensure auditors complete audits and necessary remediation within specified timeframes.

- Collaborate with the Non-Clinical UM team to ensure monitored focus areas are addressed and that process quality is tracked.

- Work with operational teams to evaluate the effectiveness and efficiency of process changes made for quality improvement.

- Ensure that new processes are accurately implemented through reports and case file reviews.

- Report issues identified to the Prior Authorization Compliance Director based on findings.

- Review updated policies and procedures, and be able to update the quality monitoring tool accordingly.

- Maintain all evidence related to quality monitoring projects.

- Track and manage daily reports received from the decision support team.

- Report any issues related to internal processes (e.g., timeliness) to the CQM manager.

- Attend department meetings, in-house services, and trainings, completing acknowledgments within the required timeframe.

- Perform all other duties as directed by management.

Education and Experience:

- Three to five (3-5) years of experience in non-clinical utilization management.

- Preferred: at least two (2) years of experience in non-clinical UM supervision or auditing.

- Proficiency in MS Office programs (Word, Excel, Outlook, Access, PowerPoint).

- Typing speed of 60 words per minute with accuracy.

- Ability to handle confidential matters responsibly.

- Strong analytical, creative problem-solving, and organizational skills.

- Capacity to work in a multi-tasking, high-stress environment.

- Effective strategy execution within timelines, delivering quality results.

- Ability to adapt and thrive in a fast-paced environment, demonstrating proactivity.

- Capable of managing multiple projects simultaneously, adjusting priorities daily, and knowing when to seek assistance with conflicting priorities.

- Self-motivated, assertive, ambitious, and possessing high personal ethics.

- Ability to collaborate with all levels of management and establish positive working relationships across various divisions in the company.

Compensation:

The pay range for this position at the start of employment is expected to be between $70,304 and $72,000 annually, depending on experience. However, the base pay offered may vary based on multiple individual factors, including market location, job-related knowledge, licensure, skills, and overall experience.

The total compensation package for this position may also include other elements, such as a sign-on bonus and discretionary awards, along with a full range of medical, financial, and other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), depending on the position offered.

Details regarding participation in these benefit plans will be provided to employees who receive an employment offer. If hired, the employee will be in an “at-will position,” and the company reserves the right to modify base salary (along with any other discretionary payments or compensation programs) at any time, including for reasons related to individual performance, overall company performance, or market factors.

As one of the fastest-growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare, and Affiliated Doctors of Orange County offer a dynamic and fast-paced work environment.

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

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