About the Role
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.
-
Active California RN license.
-
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 help 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!
