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14 Nov 2020

Full-Time Director of Quality, Risk, Compliance and Utilization Management

APLA Health – Posted by APLA Health Los Angeles, California, United States

Job Description

APLA Health’s mission is to achieve health care equity and promote well-being for the LGBT and other underserved communities and people living with and affected by HIV. We are a nonprofit, federally qualified health center serving more than 14,000 people annually. We provide 20 different services from 15 locations throughout Los Angeles County, including: medical, dental, and behavioral health care; PrEP counseling and management; health education and HIV prevention; and STD screening and treatment. For people living with HIV, we offer housing support; benefits counseling; home health care; and the Vance North Necessities of Life Program food pantries; among several other critically needed services. Additionally, we are leaders in advocating for policy and legislation that positively impacts the LGBT and HIV communities, provide capacity-building assistance to health departments across the country, and conduct community-based research on issues affecting the communities we serve. For more information, please visit us at

APLA Health is currently seeking a Director of Quality, Risk, Compliance and Utilization Management for to join our Baldwin Hills team! We offer great benefits, competitive pay, and great working environment!

We offer:

• Medical Insurance
• Dental Insurance (no cost for employee)
• Vision Insurance (no cost for employee)
• Long Term Disability
• Group Term Life and AD&D Insurance
• Employee Assistance Program
• Flexible Spending Accounts

• 10 Paid Holidays
• 3 Personal Days
• 10 Vacation Days
• 12 Sick Days
• Metro reimbursement or free parking
• Employer Matched 403b Retirement Plan


This is a great opportunity to make a difference!

Director of Quality, Risk, Compliance and Utilization Management (90016)

APLA Health & Wellness (APLAHW) is seeking a qualified individual to provide leadership and expertise to ensure the delivery of safe, high quality patient care services delivered at all clinical sites. This individual would be a member of the APLAHW senior management team. APLAHW provides culturally competent medical, dental and behavioral health services to low-income individuals in Los Angeles County, with a specific focus on the LGBT community.

• Supervises 3 managers: one each for quality, risk/compliance and utilization.
• Hires and supervises additional Quality Improvement, Risk/Compliance and Utilization staff depending on the needs of the organization.
• Represents APLA Health as the Senior Quality, Compliance/Risk, Utilization Management staff to various community associations and external agencies, including CCALAC, CPCA, HRSA and others as appropriate.
• Oversees a corporate wide quality improvement program inclusive of all staff, maintains a written quality improvement plan and annual evaluation of the plan’s effectiveness.
• In collaboration with the Medical Director, develops and maintains a performance measurement work plan and reporting calendar to ensure timely data collection, aggregation, analysis, and reporting of established quality measures related to key operational and clinical processes and outcomes.
• Develops and maintains policies and procedures related to quality management.
• Under the medical director, facilitate the monthly Quality, Compliance, Risk and Utilization Management meeting.
• Provides guidance on maintenance of APLAHW’ status as a patient-centered medical home per National Committee for Quality Assurance (NCQA) standards.
• In collaboration with the medical director and nursing director, oversees population health management plans.
• Oversees electronic storage of quality improvement reports to promote ongoing access for key stakeholders.
• In coordination with the medical director and COO, oversees a corporate compliance program, develops and maintains a written corporate compliance plan and annual evaluation of the plan’s effectiveness; ensures that all required elements of a compliance program are addressed.
• Develops and maintains policies and procedures related to the corporate compliance program.
• In consultation with the Medical Director and CEO, submits mandatory notification of known or suspected corporate compliance violations to the appropriate regulatory agencies.
• Oversees a corporate wide risk management program, develops and maintains a written corporate risk management plan and annual evaluation of the plans’ effectiveness.
• Develop and maintain policies and protocols supporting the risk management plan.
• Oversees, and develops as needed, processes for internal incident reporting, as well as external complaint and grievance management. Investigates and evaluates claims and potential claims.
• Oversees a Clinic wide patient safety program, develops and maintains a written patient safety plan and annual evaluation of the plan’s effectiveness and develops and maintains policies and procedures related to the patient safety program.
• Collaborates with the Medical Director in the investigation of clinical events including sentinel events, sentinel event near misses, and significant adverse events; leads and/or participates in the development of root cause analyses as directed by the Medical Director.
• Develops plans for and ensures all employees participate in training that will create greater awareness and meet all compliance requirements.
• Acts as Privacy Officer for the clinics.
• Oversees the process of achieving and maintaining FTCA coverage.
• Oversees the emergency management plans for each clinic site.
• Oversee the development, execution, and evaluation of an agency utilization management plan and efforts.
• Oversee the Utilization Review Program at APLA Health
• Work closely with outside agencies, such as the IPAs (Independent Provider Associations), to promote cost-effective care.
• Oversee efforts to ensure that documentation captured accurately reflects services performed and complexity of care in order to maximize health plan and IPA reimbursements.
• Coordinate with the billing department to help achieve payment maximization for services rendered


Training and Experience:
Possession of the following required: Master’s Degree in Nursing, Public Health or Healthcare Administration from an accredited college or university preferred. Prior administrative and supervisory experience in an outpatient family practice, internal medicine, or a Federally Qualified Health Center or community clinic. Experience leading quality improvement teams. Demonstrated ability to perform assigned responsibilities with minimum supervision; to maintain quality control standards; to interpret, adapt and apply guidelines and procedures. Strong verbal, written and interpersonal skills. Ability to develop and maintain cooperative relationships with staff members, patients and clinicians and work as a member of a multi-disciplinary team. Demonstrated ability to follow set routines and be alert to variations and make decisions accordingly. Sensitivity to racially, ethnically, culturally and sexually diverse populations; excellent oral and written communication skills; and knowledge of Microsoft Office. Experience with electronic health records, Must possess current CPR certification.

Knowledge of:
Working knowledge of management methods and practices in a community clinic setting or similar health care facility. Experience in developing QM and Compliance programs;. Basic knowledge of local, state and federal regulations relating to care of patients in a clinic setting, Managed Care, and Title 22 is preferred Skill in identifying problems and recommending solutions in a clear, concise and proactive manner, including recognition and resolution of costly errors. Demonstrated ability to set priorities and organize work responsibilities to insure completion of assigned tasks within agreed upon time span. Knowledge of common safety hazards and precautions sufficient to establish a safe work environment.

This is primarily an office position that requires only occasional bending, reaching, stooping, lifting and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.

Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.

An Equal Opportunity Employer: minority/ female/ disability/ veteran.

How to Apply

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Job Categories: Equal Opportunities. Job Types: Full-Time.

Job expires in 19 days.

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