Senior Director, 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) 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.