Clinical Services Manager- DMC-ODS

The Clinical Services Manager provides clinical leadership and serves as the designated Compliance Officer for CalMHSA’s multi-county Drug Medi-Cal Organized Delivery System (DMC-ODS) administrative model. This position directs clinical quality management, utilization management, and provider compliance functions, and holds organization-wide responsibility for the regional model’s compliance program, including HIPAA, 42 CFR Part 2, and DMC-ODS regulatory and contractual compliance.

Reporting to the Senior Program Manager/AOD Administrator, the Clinical Services Manager directly supervises Quality Management Clinician(s) and Quality Management Analyst(s) and provides clinical direction and compliance oversight across the regional model’s access, utilization management, provider network, and quality improvement functions. This role requires clinical licensure, substantial DMC-ODS and Medi-Cal behavioral health managed care experience and demonstrated ability to lead a clinical and compliance program, including managing audits, corrective action, and regulatory reviews. This position reports to, and partners closely with, the Senior Program Manager/AOD Administrator to ensure clinical, compliance, and operational functions of the multi-county model remain aligned.

DUTIES AND RESPONSIBILITIES include but are not limited to:

• Supervise Quality Management staff – hiring, training, workload management, performance reviews, and professional development – and direct day-to-day clinical quality management, utilization management, and provider compliance functions for the regional model.
• Serve as Compliance Officer for the regional DMC-ODS model, holding organization-wide responsibility for the compliance program (HIPAA Privacy/Security, 42 CFR Part 2, state/federal confidentiality and program integrity requirements), and lead the organization's response to DHCS audits, EQRO reviews, readiness reviews, and other oversight activities, including corrective action plans and evidence of completion.
• Direct clinical policy and utilization management, including policy/procedure/practice guideline development (ASAM criteria, DMC-ODS, Medi-Cal medical necessity, parity) and oversight of service authorization, reauthorization, and medical necessity review, including delegated review activities.
• Own the quality improvement program, including the QI Work Plan, PIP coordination, organization-wide clinical trend analysis, and provider compliance oversight (credentialing standards, site/chart review programs, clinical corrective action plans).
• Monitor program-level data (grievances, appeals, NOABDs, utilization, access, provider performance) to identify clinical and compliance risk and direct escalation, investigation, and remediation, including response to reported compliance concerns and privacy/security incidents in coordination with leadership and legal counsel.
• Act as clinical/compliance subject matter expert and external representative – providing training and technical assistance to counties, providers, and internal teams, and representing CalMHSA in clinical quality, compliance, UM, provider, county, EQRO, and DHCS meetings as the point of contact for compliance-related inquiries.
• Partner with the Senior Program Manager/AOD Administrator on program planning, budgeting, staffing, and risk management, and develop organization-wide clinical and compliance training programs, reports, dashboards, and briefings for leadership, counties, and state agencies.
• Maintain confidentiality and system integrity for all consumer demographic and behavioral health data accessed in the role.
• Perform other duties as assigned, demonstrating flexibility and commitment to organizational success.

BACKGROUND CHECK ELIGIBLE DUTIES

This position will have access to various applications that house confidential information, including county behavioral health records, Protected Health Information (PHI), substance use disorder treatment records, consumer demographic data, clinical documentation, utilization management records, provider compliance files, and quality management documentation. The incumbent must handle all confidential information in accordance with HIPAA Privacy and Security Rules, 42 CFR Part 2 regulations, applicable state confidentiality requirements, and CalMHSA security policies, ensuring that access is used responsibly while maintaining the integrity and security of systems and preventing accidental or malicious misuse.

QUALIFICATIONS –

An acceptable equivalent combination of education, experience, and skill may be considered.

EDUCATION/EXPERIENCE:

• Master’s degree in Social Work, Marriage and Family Therapy, Professional Clinical Counseling, Psychology, or related clinical field, required.
• Current California Board of Behavioral Sciences (BBS) licensure required; acceptable credentials include LMFT, LCSW, LPCC, or equivalent independent clinical licensure recognized by the BBS.
• Seven (7) years of experience in behavioral health, substance use disorder treatment, quality management, utilization management, or compliance, including at least three (3) years in a supervisory, management, or compliance leadership role.
• Substantial experience with DMC-ODS, including ASAM criteria, medical necessity, authorization processes, residential treatment, withdrawal management, and Medi-Cal documentation requirements, required.
• Experience serving as, or directly supporting, a Compliance Officer, Privacy Officer, or Security Officer function, including HIPAA and 42 CFR Part 2 compliance.
• Experience working within or directly with a County Behavioral Health Plan, particularly overseeing DMC-ODS clinical, quality, or compliance functions.
• Experience managing DHCS audits, EQRO reviews, corrective action plans, and provider credentialing/recredentialing programs.

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Clinical Knowledge & Expertise:

• Expert clinical knowledge of substance use disorder treatment, DMC-ODS services, ASAM criteria, medical necessity, and care coordination.
• Comprehensive knowledge of HIPAA, 42 CFR Part 2, and other applicable behavioral health confidentiality, privacy, and program integrity requirements.
• Strong knowledge of California county behavioral health plan operations, Medi-Cal managed care requirements, and DMC-ODS contract requirements.
• Expertise in managing audits, compliance reviews, corrective action planning, and regulatory relationships with state and federal agencies (DHCS, EQRO).
• Demonstrated ability to conduct clinical quality reviews, analyze clinical data, and identify trends, gaps, and improvement opportunities.

Leadership, Management & Compliance Skills:

• Demonstrated leadership and supervisory skills, including the ability to direct, develop, and evaluate clinical and compliance staff.
• Ability to lead organization-wide compliance and audit-readiness activities, including managing findings, corrective action, and regulatory relationships.
• Strong project management and organizational skills with ability to manage multiple clinical and compliance priorities, deadlines, and stakeholder expectations.
• Excellent written and verbal communication skills, including the ability to develop clinical policy, compliance guidance, training materials, and executive-level reports.
• Strong facilitation and stakeholder management skills, including the ability to work effectively with county leaders, providers, clinical staff, state partners, and internal cross-functional teams.

Professional Attributes & Work Style:

• Sound clinical and ethical judgment, discretion, and the ability to manage sensitive, confidential, and high-stakes compliance matters professionally.
• Strong analytical skills, including the ability to review clinical, quality, and compliance data to identify trends, risks, and improvement strategies.
• Detail-oriented and organized with strong commitment to accuracy, quality, and adherence to regulatory and organizational standards.
• Demonstrates initiative, independence, and resourcefulness in completing assignments and solving complex compliance challenges.
• Adaptable and able to manage shifting priorities and competing deadlines in a dynamic healthcare compliance environment.
• Comfortable and self-directed working in a remote environment; maintains accountability to leadership and demonstrates reliable communication.

COMPUTER SKILLS: Demonstrate the ability to use a computer and applicable computer software effectively. Intermediate knowledge of Excel & Word, PowerPoint, Adobe, and Outlook required. Experience with electronic health records, utilization management platforms, provider management systems, or data/reporting systems preferred.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is frequently required to sit and stand; use phone and headset; use hands, arms, finders to type; answer phones; write; use calculator; demonstrate strength to lift and carry materials weighing up to 10 pounds; demonstrate clear vision to read printed materials and a computer screen; hearing and speech to communicate in person and over the telephone.

SENSORY DEMANDS: The incumbent must spend long hours in intense concentration. The incumbent must also spend long hours on the computer entering information which requires attention to detail and high levels of accuracy.

MENTAL DEMANDS: There are a number of deadlines associated with this position, which may cause significant pressure. The incumbent must also attend to a wide variety of individuals regarding various topics/challenges.

REGULAR WORK SCHEDULE: Schedule varies depending on business needs; however, regular company business hours are 8:00am to 5:00pm, Monday – Friday.