Manager, Network Compliance- Clinical

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the "12 Angry Seniors." Their mission continues to guide everything we do.

Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.

Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.

At SCAN, we believe scale should strengthen-not dilute-our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.

The Job

Ensures that SCAN contracted network providers and other First Tier, Downstream and related entities (FDR) deliver timely, appropriate quality care and services to SCAN members consistent with the Centers for Medicare and Medicaid Services (CMS) and other state, federal and accrediting body requirements. Provides operational expertise to all delegation oversight processes and activities for clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR).

You Will

Manages and oversees day-to-day operations of the Delegation Oversight Unit clinical functions: Special Needs Plans (SNP), Utilization Management (UM), Denials, Facility Site Reviews/Medical Record Reviews (FSR/MRR).
Facilitates continuous quality improvement within the SCAN delegated networks by developing systems to assess, monitor and improve performance of delegated entities and other First Tier, Downstream and related entities (FDR).
Maintains audit readiness, by ongoing training, competency assessment, auditing, monitoring of metrics and developing and implementing corrective action.
Participates in internal and external department audits and assessments and prepares and drives the implementation of corrective action plans as indicated for such audits.
Develops and utilizes meaningful management reports to monitor staff productivity and department activities and to evaluate programs to identify potential issues and areas for improvement. Conducts ongoing analysis; making recommendations for process improvements in work flow, organization, communication, and overall staff and program efficiency.
Promotes compliance with and adheres to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and accreditation bodies' standards such as the National Committee for Quality Assurance (NCQA) as it relates to medical management and delegation oversight activities.
Develops, implements, and maintains department documentation including policies and procedures, desktop policies and job aids, work plans, staff education materials and other documents as requested to ensure improved efficiency, productivity and outcomes.

Collaborates with internal departments to develop policies and procedures, and implement and monitor daily activities.
Serves as a resource to internal and external customers including FDRs.
Ensures compliance with federal and state regulations and internal standards.
Supports and coordinates daily department activities by providing strong leadership.
Attends internal and external meetings, participates in and/or facilitates SCAN committees and work groups as requested.
Trains staff in Delegation Oversight compliance and regulatory standards following SCAN and department policy and procedure to achieve organizational goals and outcomes.
Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures.
Maintains staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities.
Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
Contributes to team effort by accomplishing related results as needed.
We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Actively support the achievement of SCAN's Vision and Goals.

Other duties as assigned.

Your Qualifications

* Bachelor's Degree in Nursing, related field, or equivalent experience. Master's Degree preferred.
* Active California Registered Nurse license.
* 3-5 years of Compliance experience required.
* Management experience preferred.
* Experience with delegation oversight.
* Experience working for a managed care organization such as: an HMO, IPA or Medical Group is required.
* Working knowledge of guidelines and regulations relevant to FDR Compliance including Medicare, Medi-Cal, DMHC, SNP, NCQA, and Milliman Guidelines.
* Excellent written and oral communication skills, as well as strong interpersonal, critical thinking, and analytical skills.
* Excellent organizational, decision-making and multi-tasking skills.
* Demonstrated ability to work with all levels of staff, within and external to the organization to achieve goals.
* Experience with coordinating diverse groups of individuals to achieve success of the overall program.
* Ability to prioritize multiple and competing tasks, work independently and in a team environment.
* Ability to work well in a fast-paced and dynamic environment with limited supervision.
* Proficient in MS Office.
* Travel 20+% of the time- Must have a valid driver's license, automobile insurance and reliable transportation.

What's in it for you?

• Base Pay Range: $106,200 to $153,705 annually
• Work Mode: Mostly Onsite (In office 2 days per week on Tuesday/Wednesday)
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, 2 volunteer days, and Recharge days
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)