Director of Clinical Audit & Performance Excellence

Advanced Medical Management, Inc.; Long Beach (CA); On-site; USD 150,000 - 210,000; Full time

Benefits offered by this job

Health coverage

Vision premiums

FSAs

401(k)

PTO and sick leave

Holidays

Tuition reimbursement

Company outings

Job summary

Seoul Medical Group (SMG) seeks an experienced Director of Clinical Audit & Performance Excellence to lead our enterprise Clinical Audit Program, ensuring CMS, NCQA, DMHC/DHCS compliance while driving quality and operational improvement.

You will set audit governance, develop standardized methodologies, oversee dashboards and reports, and partner with senior leaders to elevate care quality and compliance across UM, Case Management and delegated health plans.

Qualifications

• Bachelor's degree in Nursing, Healthcare Administration, Clinical Sciences, Public Health, or related field.
• 10+ years of Managed Care experience.
• 8+ years of Utilization Management experience.
• 5+ years leading Clinical Audit, Quality, Compliance, or Performance Improvement programs.
• Experience with Medicare Advantage, delegated MSO or Health Plan environments, CMS audit readiness, and NCQA accreditation.
• Strong knowledge of CMS, NCQA, DMHC, DHCS regulations and clinical documentation standards.
• Leadership in enterprise quality improvement, audit governance and executive reporting.

Responsibilities

• Lead the enterprise Clinical Audit Program across UM, Case Management, Appeals, Medical Director Reviews, Prior Authorization, Concurrent Review, and Delegation Oversight.
• Develop and maintain standardized audit methodologies, governance frameworks, audit tools, and evidence standards.
• Oversee enterprise audit reporting, quality scorecards, performance dashboards, and executive presentations.
• Lead root cause analyses, CAP validation, and continuous process improvement initiatives.
• Ensure readiness for CMS, NCQA, DMHC, DHCS, delegated health plan, and external regulatory audits.
• Partner with executive leadership, Compliance, Medical Directors, Operations, IT, Provider Relations, and Health Plans to improve operational quality and regulatory compliance.
• Develop enterprise IRR programs and auditor calibration processes.
• Monitor audit trends, identify systemic risks, and recommend performance improvement strategies.

Skills

Leadership

Regulatory knowledge

Analytics

Stakeholder management

Auditing

Education

Bachelor's degree in Nursing, Healthcare Administration, Clinical Sciences, Public Health, or related field

Job description

Seoul Medical Group (SMG), one of the nation's leading Independent Practice Associations (IPA), is seeking an experienced Director of Clinical Audit & Performance Excellence to lead our enterprise Clinical Audit Program. This strategic leadership role is responsible for developing and overseeing a standardized clinical audit framework that ensures compliance with CMS, NCQA, DMHC, DHCS, delegated health plan requirements, and enterprise policies while driving continuous quality and operational improvement.

The Director serves as the organization's independent authority for clinical audit methodology, audit governance, corrective action validation, performance analytics, and audit readiness across Utilization Management (UM), Case Management, and delegated health plan operations.

Key Responsibilities

• Lead the enterprise Clinical Audit Program across UM, Case Management, Appeals, Medical Director Reviews, Prior Authorization, Concurrent Review, and Delegation Oversight.
• Develop and maintain standardized audit methodologies, governance frameworks, audit tools, and evidence standards.
• Oversee enterprise audit reporting, quality scorecards, performance dashboards, and executive presentations.
• Lead root cause analyses, corrective action plan (CAP) validation, and continuous process improvement initiatives.
• Ensure readiness for CMS, NCQA, DMHC, DHCS, delegated health plan, and external regulatory audits.
• Partner with executive leadership, Compliance, Medical Directors, Operations, IT, Provider Relations, and Health Plans to improve operational quality and regulatory compliance.
• Develop enterprise Inter-Rater Reliability (IRR) programs and auditor calibration processes.
• Monitor audit trends, identify systemic risks, and recommend performance improvement strategies.

Qualifications

Required

• Bachelor's degree in Nursing, Healthcare Administration, Clinical Sciences, Public Health, or a related field.
• 10+ years of Managed Care experience.
• 8+ years of Utilization Management experience.
• 5+ years leading Clinical Audit, Quality, Compliance, or Performance Improvement programs.
• Experience with Medicare Advantage, delegated MSO or Health Plan environments, CMS audit readiness, and NCQA accreditation.
• Strong knowledge of CMS, NCQA, DMHC, DHCS regulations, prior authorization, appeals, medical necessity criteria, and clinical documentation standards.
• Demonstrated experience leading enterprise quality improvement, audit governance, corrective actions, and executive reporting.

Preferred

• Certified Professional in Healthcare Quality (CPHQ).
• Experience with MCG and/or InterQual criteria.
• Experience in multi-health plan delegated environments, Appeals oversight, and Medical Director collaboration.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!