Senior Manager, Clinical and Regulatory Operations

Job Description

The Senior Manager, Clinical and Regulatory Operations, is responsible for leading clinical case operations, regulatory interpretation, and clinical decision stewardship across all grievance, appeal, and State Fair Hearing cases. This position ensures that clinical and non-clinical case handling meets medical necessity standards, regulatory requirements, internal policy expectations, and quality-of-care obligations across all product lines, including Medi-Cal, Medicare, Marketplace, and delegated entities.

The Senior Manager 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. The role ensures strong collaboration with Utilization Management, the UM Medical Director, physician reviewers, Compliance, Member Services, Provider Network Management, claims teams, and the Center of Quality & Excellence to support compliant, timely, and high-quality case handling.

The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.  Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for drivi…

Qualifications

Education Required

• Bachelor's Degree in Nursing or Related Field

Education Preferred

• Master's Degree in Business Administration or Related Field

Experience Required:

• 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. Demonstrated experience overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting. 
• Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations. 
• Experience developing and managing corrective action plans and driving sustainable remediation. Experience collaborating with delegated entities, plan partners, or subcontracted networks. 
• Experience leading teams, projects, initiatives, or cross-functional groups. 

Preferred:

• Experience with analytic dashboards and visualization tools (Power BI, Tableau).

About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.