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<p>Salary Range:&nbsp;&nbsp;$149,502.00&nbsp;(Min.) -&nbsp;$201,827.00&nbsp;(Mid.) -&nbsp;$254,152.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Director, Technology Solutions &amp; Support services responsible for overseeing the development and implementation of technology solutions and ensuring the provision of top-notch support services to meet organizational needs. The Senior Director is responsible for providing leadership and direction to L.A. CARE's various shared technology services’ teams. The Senior Director is also responsible for strategic planning, development, and implementation of special technology solutions to drive organizational success. The role is responsible for managing cross-functional teams, optimizing technology operations, and ensuring the delivery of high quality support services to internal and external stakeholders.&nbsp;</p><p>The Senior Director directs all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Provide strong leadership and mentorship to a team of technologists responsible for ensuring that Information &nbsp;Technology (IT) systems and services are available and performing at optimum levels for the business. Ensure all IT changes and deployments are of highest quality, and the production systems are stable in the event of changes. &nbsp;Responsible for managing internal and external stakeholders, designing and implementing IT strategies, reducing production and security risks, and maintaining systems and operations within the service level agreements (SLAs) established by the company. Performs analysis of incidents and problems, creating reports for status and decision making with focus on problem prevention. Provides proactive and retrospective metrics and analytical reporting to internal customers and client executives; including critical batch processing reports. &nbsp;Builds repeatable processes, leveraging best practices with focus on continuous improvement with focus on automation. Ensures the integrity of all information systems and corporate information through the implementation and maintenance of established system management practices, controls and SLAs.</p><p>Responsible for overseeing the following IT functions, but not limited to -</p><p>Network Operations Center (NOC) and IT Production Control<br>Provides oversight, development, and management of IT fault and performance monitoring services utilizing Dynatrace to ensure that any technology issues can be detected and quickly resolved. Responsible for activating and managing IT Major incident management teams for incident response until resolution. Collaborates heavily with Security Operations Center (SOC) to ensure the L.A. CARE Assets and networks are secure. Ensures that Batch design, support and operations run per the established SLAs and standards.&nbsp;</p><p>IT Service Desk and IT Asset Management<br>Responsible to ensure that the L.A. CARE Health end-user have the proper technology they need to perform their daily jobs. Manages the Service Desk ticket queue, developing monitoring and reporting, improving processes, and resolving end-user technology issues promptly. Responsible for active problem management and problem prevention, and implementation of newer technologies such as AI to improve the quality of support services.&nbsp;</p><h4>Duties Continued</h4><p>IT Quality Assurance and Control&nbsp;</p><h4>Develop and manage a roadmap to setup, and mature a centralized IT Quality Control and Assurance unit at L.A. CARE. Oversee and manage the quality control processes such as smoke testing, integration testing, performance testing, end-to-end testing, security testing. Responsible for driving test automation and QA efficiency improvements per industry's best practices. Engage in the transformation to an Agile and Product driven planning and deployment cycle which results in continuous delivery of high-quality products and services on time and within budget.</h4><h4>Change and Release Management </h4><h4>Oversee the release management team in managing enterprise Software and configuration change and deployments. Manage a roadmap to reduce overall effort required to manage a release cycle, transition to Github and Azure DO, SonarQube, Continuous Integration/Continuous Delivery (CI/CD) and DevSecOps adoption. Drive release execution improvements that result in deployment efficiencies, including automation of manual processes. </h4><h4>Negotiate and manage contracts with technology vendors and service providers supporting the IT Shared technology Services and support functions. Provide support to internal and external audits. Provide product and process quality reports to key stakeholders which summarize information and trends. </h4><h4>Achieve financial objectives by preparing budget, monitoring and scheduling expenditures, analyzing variances, and initiating corrective actions. </h4><h4>Develop goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.&nbsp; Prepare briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's regulatory position and policy. Develop regulatory position and policy based on research and evidence. </h4><h4>Perform other duties as assigned.</h4><h4>Education Required</h4>Bachelor's Degree in Computer Science or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p>Required:<br>Minimum of 8 years experience with increasing responsibilities for management and support of information systems and information technology</p><p>Minimum of 7 years leading staff or supervisory/management experience.</p><p>Project management experience using a variety of methodologies for the planning, implementation and support of systems in a complex environment</p><p>Experience and working knowledge in writing and managing I.T. policies and procedures.</p><p>Experience in Production/Issue Management and Quality Assurance disciplines, standards, processes and workflow.</p><p>Experience with testing the configuration of core systems and the related surround systems, applications, and databases, Process Communication Tracking (PCT), QNXT Migration Utility, Claims Test Pro.</p><p>Experience with utilizing SDLC and related configuration change management.</p><p>Experience with health plan configuration, pricing methodologies, and American Health Information Management Association (AHIMA) coding standards.</p><p>Experience with ICD-9 CM, ICD-9 PCS, ICD-10 CM and ICD-10 PCS, CPT, Revenue, HCPCS, UPN, Redbook, RUG and Diagnosis Related Group (DRG) coding systems.</p><h4>Skills</h4><p>Required:<br>A deep understanding of a broad range of technologies and the mastery of applying technology to deliver differentiated value to Business and Customers.</p><p>Strong understanding of Software Development Lifecycle, Agile methodologies, IT Service Management and IT Quality Control &amp; Assurance processes.&nbsp;</p><p>Excellent business acumen, presence, project management, presentation, and organizational skills.</p><p>Excellent decision-making, analytical, and leadership skills.</p><p>Passionate about inventing and delivering customer-focused solutions to ambitious and ambiguous challenges.</p><p>Proficiency with Microsoft Office suite products.</p><p>Strong interpersonal, written and verbal communication, and presentation skills.</p><p>Ability to interact and develop effective working relationships across organizational lines.&nbsp;</p><p>Demonstrated ability to build and lead teams of various size in delivery of services to stakeholders.</p><p>Detail oriented; strong organizational, analytical and critical thinking skills with the ability to manage and prioritize multiple responsibilities, deadlines and changing priorities.</p><p>Possess a high level of initiative, be a self-starter, self-directed, highly motivated and able to work in a fast-paced environment.</p><p>Understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing</p><p>Knowledge of Systems Development Life Cycle (SDLC) procedures in planning system configuration changes</p><p>Knowledge of standard programming and logic to facilitate the maintenance of system configuration files and tables, along with supporting documentation.</p><p>Working knowledge of quality system requirements</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Information Technology Infrastructure Library (ITIL) Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Must be currently eligible to work in the US for any employer without sponsorship.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Service Desk, Claims, Medical Coding, Customer Service, Insurance, Healthcare                                                    </p>

L.A. Care Health Plan

Senior Director, Technology Solutions and Support Services

<p>Salary Range:&nbsp;&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Manager, Community Resource Centers (CRC) provides leadership, strategic direction, relationship management and oversight of the L.A. Care CRC facility operations. The CRC allows L.A. Care to fulfill its mission to serve vulnerable populations by providing services in the local communities where our members reside, throughout Los Angeles County. CRCs are standalone locations that operate independently similar to retail storefronts with significant walk-in traffic consisting of both health plan members and non-members. The average size of an CRC is 8 – 12,000 square feet. This position is responsible for the direct supervision, recruitment, training, and performance evaluation of CRC staff. With guidance from CRC leadership and research, the CRC Manager will align CRC programming and services to the organization’s strategic priorities and community needs. The role is responsible for making quality informed decisions that are in the best interest of L.A. Care and its stakeholders.&nbsp;</p><p>The Manager, Community Resource Centers is also responsible for the day to day implementation and evaluation of the Plan Partner joint strategy that will provide hubs of enhanced member-focused services and programming and benefits to the community through addressing social determinants of health. This includes facilitating the work of Plan Partner staff to serve their members as well as facilitating the activities of L.A. Care remote workers assigned to an CRC. Responsible for the development and management of community partner and local provider relationships that support in engaging participants to CRC activities and services. This position functions as the L.A. Care management representative in external stakeholder community meetings on behalf of the CRC. Works in collaboration with internal departments to enhance CRC operations in support of improved health care outcomes for L.A. Care members and the community. This position oversees the annual marketing, promotional, community events, and health screening programs for their assigned CRC. This person will independently manage an off-site location and will act to resolve higher-level or complex issues that may impact the overall operation of the CRC and its brand all while maintaining open lines of communication with higher level leadership.&nbsp;</p><p>Manages all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p><br>Operations and Strategic Support: Provides leadership, strategic direction, relationship management and oversight of the L.A. Care CRC facility operations. With guidance from CRC leadership and research, the CRC Manager will align CRC programming and services to the organization’s strategic priorities and community needs. Manages relationships with onsite Plan Partner staff and management and contributes to the strategic plan and implementation of joint programs for Medi-Cal members. Facilitates activities of L.A. Care staff assigned to work remotely at an CRC Promotes strategic and informed CRC programming and activities that include health education, physical fitness, wellness, and social supports to increase member engagement and retention for L.A. Care’s CRC Brand and supports the goals of the joint L.A. Care/Plan Partner CRC initiative. Manages the development, implementation, and evaluation of CRC operations, programming and services. Oversees marketing and promotional event activity to build awareness and understanding of CRC programs and benefits. Oversees implementation of the annual CRC health screening programs. Identifies, assesses, and manages vendor contracts and Memoranda of Understanding (MOUs) and the related logistical coordination to ensure high quality services aligned with the CRC mission. The role is responsible for making quality informed decisions that are in the best interest of L.A. Care and its stakeholders. Collaborates closely with internal stakeholders, including the Sales and Marketing team to promote L.A. Care’s brand identity, lines of business and CRC initiatives through the development of marketing materials, special events, and other related activities. Works in collaboration with internal departments to enhance CRC operations in support of improved health care outcomes for L.A. Care members and the community. Understands when to adequately engage leadership support to resolve sensitive human resources issues or political situations. Actively seeks input from direct supervisor to make timely and well-informed decisions.</p><p>People and Performance Management: Manages CRC staff, establishes clear responsibilities and processes for monitoring work and measuring results. Assigns work, provides clear expectations of the role, and evaluates and manages performance standards and goals. This position is responsible for the direct supervision, recruitment, training, and performance evaluation of CRC staff. Provides guidance and support to establish processes that help resolve escalated requests from members and community participants in order to address health and social service needs. Creates a team environment that fosters a feeling of belonging and strong team morale among staff. Promotes open dialogue and collaboration among the team while establishing common objectives aligned to organizational employee engagement strategies.&nbsp;</p><p>Stakeholder Engagement: Serves as leader in exploring, building and supporting new partnerships that will prove strategic to enhance local health initiatives and innovative programs. Co-management of location in shared operational project with plan partner. Functions as L.A. Care management representative in external stakeholder community meetings on behalf of the CRCs, as needed.&nbsp;</p><p>Reporting Management and Data Monitoring: Supervises the collection and synthesis of quantitative and qualitative information. Tracks data on the individual CRC activities and utilizes the data to drive decision making across CRC services. Ensures that new activities and outcomes are tracked as part of the data collection.&nbsp;</p><p>Perform other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><br>Required:&nbsp;<br>At least 5 years of demonstrated experience with ability to effectively and efficiently allocate resources. At least 2 years of supervisory/management experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Experience with planning community health-focused events and in managing simple to complex projects, preferably in the managed care field.</p><p>Health education experience and/or able to identify and manage external community resources that help address the social determinants of health.</p><p>Experience working with ethnically diverse populations in a community setting.&nbsp;</p><p>Preferred:<br>Prior work experience managing nonprofit/ social services, specifically in the area of government funded programs.</p><h4>Skills</h4><p><br>Required:</p><p>Solid knowledge of health care and various managed care programs including Medi-Cal, Medicare, Covered CA, etc., as well as basic public health and community health principles.</p><p>Familiarity with health data analysis and collection.</p><p>High degree of initiative, a self-starter and the ability to work independently.</p><p>Strong verbal and written communication skills and ability to make clear presentations.</p><p>Strong interpersonal skills and a demonstrated ability to work collaboratively as a member of a diverse team.</p><p>Preferred:<br>Intermediate skills in the use of Microsoft Word, Excel, PowerPoint, and database programs preferred.</p><p>Preferred:<br>Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</p><p>Flexibility regarding hours to meet the business needs of the center, which may require weekends and evenings.</p><p>Travel to offsite locations for work.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Relationship Manager, Medicare, Public Health, Social Services, Performance Management, Customer Service, Healthcare, Service, Human Resources                                                    </p>

Manager, Community Resource Centers

<p>Salary Range:&nbsp;&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Provider Network Account Manager III is responsible for all aspects of the L.A. Care (LAC) provider contracting and relationship management process, including drafting, reviewing, negotiating and implementing phases of contracts, and building, nurturing, and maintaining positive working relationships between LAC and its network of providers. Assigned accounts include multiple large provider organizations (i.e. Participating Physician Group (PPGs); Hospitals; Ancillaries; etc.), or individual practitioners, in a single or multiple locations. The Account Manager III is responsible for representing LAC in their partnership with contracted and non-contracted providers, at all times. The Account Manager III is responsible for maintaining an in-depth understanding of LAC governing regulations, policies and procedures, operating standards, provider contracts, and provider performance and needs. The Account Manager III leverages that information to identify, develop, and conduct relevant and tailored provider orientation sessions, makes educational visits about LAC practices, policies, and requirements, and works to resolve provider issues. The Account Manager III is responsible for monitoring and managing network adequacy by assuring appropriate access to services throughout L.A. County, and beyond as necessary, to comply with State and Federal requirements for all product lines of business (Medicaid, Medicare, and Commercial). The Account Manager III is responsible for the initial on-board training of new managed care contract provider partners, and for ensuring their provider accounts maintain appropriate trainings and credentials to care for LAC members.</p><p>Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Responsible for identifying, contacting, and actively soliciting qualified providers and/or provider organizations to participate with LAC; assuring the financial integrity of LAC is maintained through rate negotiation; and, ensuring contract requirements are adhered to, including language, terms, and reimbursement requirements. Responsible for the project management of all contract implementations and renegotiation functions, from pre-contracting to activation, according to pre-determined internal guidelines and financial standards, while ensuring a smooth transition of services for members. Responsible for drafting contract clauses/addenda, review, and negotiating new contracts/amendments and other contracting related documents based on LAC contracting guidelines, parameters, and standards, including leadership strategy discussions; implementing contracts/amendments across LAC; and providing in-service orientation meetings with providers. Responsible for monitoring managed care contracts for renewals and expirations.</p><p>Acts the liaison between Provider Network Management (PNM) and other internal Plan departments, as necessary, to resolve complex issues, and to effectively deliver accurate, timely, and appropriate information to their assigned accounts. Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues. Monitors timely receipt of contractually required reporting. Acquires and maintains a functional working knowledge of applicable systems like QNXT, Visual Cactus, and proprietary provider databases, and routinely relays information about additions, deletions, or changes to the LAC PNM and Provider Data Management (PDM) department. </p><p>Researches and resolves contractual interpretation, operational and/or payment issues; researches and resolves incoming escalated provider inquiries within specified guidelines; educates providers on new protocols, policies, and procedures. Ensures provider database and documentation is up-to-date, accurate, and complete.</p><p>Maintains a complete understanding of LACs reports and metrics to evaluate the performance of assigned providers and/or provider organizations, and use the data to develop and implement methods to improve </p><p>relationships with all providers. Responsible to assist in all corrective actions required, up to and including termination, following LAC policies and procedures, and applicable contractual and regulatory requirements.&nbsp; </p><h4>Duties Continued</h4><p>Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues.&nbsp; </p><p>Serve as a communication link between provider accounts and LAC. Complete regularly scheduled meetings (site visits, or conference calls) with all accounts. Translate information exchange, ideas, requests and other inquiries into actionable items for improved contracting/relationship management and enhanced operational service delivery.</p><p>Support all of the LAC PNM departments (Oversight and Monitoring; Engagement and Strategy; Data Management; and, Operations). Support all of the LAC PNM groups; assist in the development and distribution of provider engagement material (trainings, notices, newsletters); assist in oversight and monitoring efforts; implement LAC provider strategies; and assist in improving the quality of provider data, as needed.</p><p>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p>Required:<br>Minimum of 4 years of experience in contracting and/or regulatory analysis in managed care or healthcare industry.</p><p>At least 4 years of healthcare experience in Managed Care; or, with a physician group, clinical-based organization, and/or in a hospital/facility setting.</p><h4>Skills</h4><p>Required:<br>Good organizational skills and demonstrate excellent attention to detail and follow up skills.</p><p>Knowledgeable financial and financial risk analysis.</p><p>Competent computer skills; MS Office skills required.</p><p>Excellent customer service skills with the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities and utilize time management skills to meet deadlines.</p><p>Must have excellent written and verbal communications skills and the ability to communicate effectively with management and non-management personnel, and LAC provider network physicians.</p><p><br>Possess a professional and mature demeanor at all times.</p><p><br>Ability to work in a fast-paced department independently and handle multiple tasks; work with interruptions and deal effectively with confidential information.</p><p>Preferred:</p><p>Knowledge of ICD-9, ICD-10, and Current Procedural Terminology (CPT) codes desired.</p><p>Proven ability to work with a diverse group of people, including physicians, support staff, coworkers and management.</p><p>Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Medical Coding Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</p><p>Travel to offsite locations for work.</p><p>Total Provider Management (TPM):&nbsp; Ensures that the LAC standard provider dataset is complete, accurate, and current. Provides network adequacy analysis and data to the Network Account Managers for the purpose of monitoring and evaluating existing contracts and the need for additional providers based on ongoing network adequacy analysis. Ensures timely submission of provider data, facilitates remediation of data errors, monitors provider data submission and data quality, and performs necessary data analysis.&nbsp; Responsible for the data management of assigned accounts from data collected prior to contracting, through activation, and the ongoing submission of provider data in accordance with regulatory requirements and LAC contractual requirements. </p><p>Required: Experience in provider data regulatory reporting and provider directory management.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Relationship Manager, Medical Coding, Medicare, Medicaid, Customer Service, Healthcare                                                    </p>

Provider Network Account Manager III

<p>Salary Range:&nbsp;&nbsp;$67,186.00&nbsp;(Min.) -&nbsp;$87,342.00&nbsp;(Mid.) -&nbsp;$107,498.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals &amp; Grievance (A&amp;G) program for L.A. Care Health Plan members under the direct supervision and management of the A&amp;G Nurse Specialist, RN and/or Medical Director. This position provides assistance to members with health care access and benefit coordination issues, ensuring that clinical grievances and complex issues are investigated and resolved to the member’s satisfaction consistent with L.A. Care Health Plan and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care Health Plan Lines of Business.</p><h4>Duties</h4><p>Work with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and determination. Performs clinical review of medical records related to grievances and appeals. Responsible for handling member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.</p><p>Reviews grievance cases that require immediate clinical quality of care, initial coding of member grievance and evaluation and/or require immediate pre-service authorization evaluation.</p><p>Investigate Provider Disputes/PDR and prepares clinical summary for Medical Director determination. </p><p>Work with the external providers and Participating Physician Group (PPGs) representatives to obtain relevant medical records and communication documentation.</p><p>Investigation and preparation of State Fair Hearing cases as assigned.</p><p>Prepare complaint files for Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DMHC), and external review organization (QIO or IRE).&nbsp; Process the case thru to effectuation and final case documentation in the A&amp;G system of record.</p><p>Work with Utilization Management and PNO to facilitate completion of resolution determination.</p><p>Investigate, prepare summary and work with Medical Directors to resolve expedited cases within regulatory timelines. Maintain knowledge of regulatory changes related to all grievances and appeals and meets regulatory requirements. Refers cases for further follow-up or notification as appropriate, e.g. fraud and abuse cases shall be forwarded to Compliance Department.</p><h4>Duties Continued</h4><p>Outreach to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps as needed.&nbsp; In instances where necessary, send written notifications to appropriate parties. All interactions including verbal outreach and written communication will be documented in the A&amp;G system of record. </p><p>Participates inter-rater reliability training and assessments.&nbsp; </p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><strong>Required:</strong><br>At least 4 years of clinical nurse and managed care experience.</p><h4>Skills</h4><p><br><strong>Required:</strong><br>Excellent interpersonal and communication skills.&nbsp;</p><p>Good working knowledge of regulatory requirements/standards.&nbsp;</p><p>Computer literacy and adaptability to computer learning.&nbsp;</p><p>Time management and priority setting skills.</p><p>Must be organized and a team player, able to work effectively with various internal business units, Plan Partners, participating provider groups, and external agencies.</p><h4>Licenses/Certifications Required</h4>Licensed Vocational Nurse (LVN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><strong>Required:</strong><br>License Vocational Nursing (LVN)</p><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    LVN, Nursing, Medicaid, Medicare, Healthcare                                                    </p>

Customer Solution Center Appeals and Grievances Nurse Specialist LVN II

<p>Salary Range:&nbsp;&nbsp;$91,536.00&nbsp;(Min.) -&nbsp;$121,286.00&nbsp;(Mid.) -&nbsp;$151,034.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Network Administrator III is responsible for providing network support for the mission critical network systems for L.A. Care. This involves troubleshooting IP equipment/LAN/WAN problems, routine administration tasks, and performance tuning. This position acts as an escalation point for the junior network staffs regarding network related problems.</p><p>Performs troubleshooting of LAN/WAN equipment i.e. CISCO, etc. Conduct daily routine administration and maintenance of all network devices. Monitors network to ensure constant uptime. Supports and maintains firewall and network security policies and IDS. Implements new technologies platforms for the network environment. Must be able to troubleshoot issues quickly to resolve the problem. Participate in Disaster&nbsp;Recovery Exercises to demonstrate the capability of establishing network connectivity in the event of an outage. Provide support in a 7x24 operation. Prioritization, Multitasking, Training, I.T. projects, and writing SOPs. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Work closely with other technical teams to determine future network needs and plan for network changes.</p><p>Develop methods and tools to be used to test to implement new LAN/WAN equipment.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Configure routing protocols such as EIGRP, OSFP, and BGP.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Engage in regular network troubleshooting and resolve network connectivity issues.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Analyze the current network structure and submit comprehensive reports to manager on how to make the network more efficient.&nbsp;&nbsp;&nbsp; </p><p>Create projects that are designed to either add functionality required by the company or to address ongoing network failure issues.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Maintain network performance by performing network monitoring and analysis, and performance tuning, troubleshooting network problems and escalating problems to vendor or lead network administrator.&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Secure network by developing network access, monitoring, control, and evaluation, maintaining documentation. </p><p>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:</p><p>Minimum of 5 years of experience as a network administrator.</p><h4>Skills</h4><p>Required:</p><p>Must have critical thinking skills and a team player. </p><p>Must have strong written and verbal communication, project management, and organization skills.</p><p>Demonstrate the ability to lead the network team on technical issues and act as a backup to the manager.</p><p>Demonstrate working knowledge of network equipment and software (Cisco Routers, Switches, firewalls, F5 Bigip, IPS/IDS, LAN/WAN).</p><p>Demonstrate working knowledge in routing protocols such as BGP, EIGRP and OSFP.</p><p>Demonstrate working knowledge in Layer 2 network switching such as VLAN, Trunking, VTP and others.</p><p>Demonstrate working knowledge in advance network troubleshooting and work with other teams or departments to resolve complex issues.</p><h4>Licenses/Certifications Required</h4>Cisco Certified Network Professional (CCNP)<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                </p>

Network Administrator III

<p>Salary Range:&nbsp;&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Payment Integrity Analyst III is responsible for leading or assisting in vendor implementations and configuration, algorithm/edit customizations, overpayment remediation, as well as other Payment Integrity functions. The position is also responsible for supporting Payment Integrity solutions focused on trending overpayment and refund reasons to identify and fully develop pipeline of new Payment Integrity initiatives.&nbsp; These initiatives include additional overpayment project pipeline as well as development of cost avoidance practices. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Serves as vendor oversight monitoring to ensure proper submission of files and correct invoicing as well as monitoring QA metrics to meet all vendor estimates. Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment cost avoidance.</p><p>Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success.</p><p>Fields and responds to escalated requests (including research) for all inquiries both internal and external; Fields and responds to Provider Dispute Resolution (PDR) requests stemming from Payment Integrity activities; supports correspondence in identification of trends for overpayment opportunities resulting in future pipeline activity.</p><p>Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review.</p><p>Serves as a subject matter expert and leads and/or assists in algorithm/edit customizations, as well as all vendor implementations as needed. Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:</p><p>At least 3 years of experience in Cost Avoidance and/or Coordination of Benefits or in Payment Integrity.</p><p>At least 5 years participating in healthcare (Medicare, Medicaid, Commercial).</p><p>At least 5 years of experience with health care data.</p><p>Experience in project implementation.</p><h4>Skills</h4><p><strong>Required:</strong><br>Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.</p><p>Working knowledge of claims coding and medical terminology. Solid understanding of standard claims processing systems and claims data analysis.</p><p>Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.</p><p>Expert knowledge of healthcare reimbursement concepts.</p><p>Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills.</p><p>Must be collaborative ability to establish credibility quickly with all levels of management across multiple functional areas.</p><p>Must be able to present findings across all departments.</p><p>Must be familiar with coordinating benefits between health plan payers.</p><p>Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.</p><p><br>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Medicaid, Medicare, Insurance, Healthcare                                                    </p>

Payment Integrity Analyst III (ALD)

<p>Salary Range:&nbsp;&nbsp;$55,245.00&nbsp;(Min.) -&nbsp;$69,045.00&nbsp;(Mid.) -&nbsp;$82,867.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Community Resource Center (CRC) Specialist III builds and maintains meaningful relationships with members of the community, L.A. Care departments, partner health plans, community based agencies, government agencies, and CRC vendors and instructors. The role leads community and provider outreach and engagement initiatives to increase member traffic at a CRC and bridges members of the community to physical and health education programs, classes and resources. Acts as a liaison to the L.A. Care on CRC marketing and promotional initiatives to meet operational needs. Implements processes including coordination of member service support across L.A. Care departments and promote positive health care outcomes. Provides extensive consultation on health care access issues, and identification of resource needs based on social drivers identified through a health assessment process. This position also conducts ongoing member assistance and follow-up in select cases. Collaborates with cross-functional L.A. Care health plan departments The CRCs serve anyone in the community in which they are located; and therefore, this role will provide expertise on referral processes to connect non-member cases to the appropriate external resources.</p><p>Participates in the planning, and development, implementation, and analysis of CRC services, programming, and vendor management. This role may serve as a lead on special projects through the development and implementation of a work plan, technical procedures, and relationship management ensuring successful implementation of CRC initiatives. &nbsp;Acts as a &nbsp;Subject Matter Expert, serves as a resource and mentor for other staff. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</p><h4>Duties</h4><p>Outreach and Engagement: (25%) &nbsp;<br>Builds, maintains, and nurtures meaningful relationships with key internal and external stakeholders; and, is an ambassador to grow CRC partnership brand recognition. &nbsp;Identifies key community stakeholders, assesses community needs, and gathers and analyzes data to inform management with an integrated approach to outreach activities and targeted member engagement. &nbsp;Plan, develop, analyze and implement member and community engagement activities to increase member traffic at the CRCs. Makes recommendations for bridging members of the community to physical and health education programs and classes which will enhance health outcomes and member experience. &nbsp;Responsible for communications and marketing efforts through multiple platforms to increase member traffic at assigned CRC; and, engages and educates members of the community on L.A. Care and CRC programs. Responsible for CRC outreach and engagement opportunities relevant to the mission of L.A. Care and the CRCs; recommends to senior management in the development and implementation of &nbsp;work plans. &nbsp;Identifies and recommends what outreach activities to prioritize &nbsp;and implement tactics to attract new L.A. Care and partner health plan members to participate into the CRC services and programs. Responsible for collecting, transporting, and distributing CRC promotional items to community partners with the goal of generating brand awareness across various L.A. Care membership communities and geographical areas in Los Angeles County.</p><p>Cross-Collaboration: &nbsp;(25%)<br>Oversees the community initiatives leveraging relationships within L.A. Care, partner health plans, and with community stakeholders to promote access to health care programs, classes, and preventative services offered at the CRC. &nbsp;Educates other L.A. Care departments on the necessary steps to implement relevant services and activities that will resonate with and engage members of the CRC community. &nbsp; &nbsp;</p><p>Implementing Strategic Initiatives: &nbsp;(20%) &nbsp;<br>Leads &nbsp;the implementation of special projects and specific tasks that &nbsp;must be &nbsp;completed in order to ensure project, initiatives, and events are successfully implemented within the required timeframe. Proactively monitors risks and provides recommendations and implements mitigation plans to keep initiatives on-track. &nbsp;Maintains consistent documentation of project deliverables, tracks and reports project status. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</p><h4>Duties Continued</h4><p>High-Touch Customer Focus: (15%)&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Performs high quality in-person service and contributes to the extended-hour schedule of the CRC to support members and visitors that may need services outside of regular operating hours and days based on business needs. &nbsp;Provides support in the creating of child creating of activities and programs to support children development while parents and guardians attend a class or service appointment at the CRC.</p><p>Day-to-Day Representation: (15%)&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Guides the coordination of member-centric customer service to respond and resolve simple inquiries and complex questions and bridges members to appropriate resources. &nbsp;Creates resource guides and reference materials to identify available CRC, L.A. Care and Plan Partner benefits, resources, and programs to meet the member/visitor needs. &nbsp;Provides guidance and support staff to identify, understand, and master meaningful program and benefit information and resources to inform and educate members, community residents, and other stakeholders. Implements the appropriate approach to identify member or visitor resource needs in complex situations and takes action to link the member/visitor to those services, programs, or resources. &nbsp;Informs L.A. Care and Plan Partner members of health care tailored services including Care Management, Social Services, Health Education, and others. Actively identifies gaps in CRC services, resources, and programs, delivers recommendations for new programs and proposes solutions for the implementation of new services.</p><p>Performs other duties as assigned.&nbsp; (10%)&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</p><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree<h4>Experience</h4><p>Required:<br>At least 1 year of community work focused on health care, public health, or health education or</p><p>At least 1 year of operations work experience with community events, leading complex projects, and managing relationships with multiple stakeholders or experience related to health plan member services, health plan member benefits and knowledge of any of the following services: Care Management, Social Services, Health Education, or other social service or clinical teams.</p><p>Product experience including knowledge of at least one of the following health care programs: Medicaid/Medi-Cal, Covered California, Medicare, or Medicare Dual Special Needs Plan.&nbsp;</p><p>Minimum of 1 year experience related to marketing, brand awareness tactics, or social media&nbsp;</p><p>Experience with database software, data entry, and reporting process.&nbsp;</p><p>Preferred:<br>Minimum of 3 years experience with database software, data entry, and reporting processes. Salesforce knowledge.</p><h4>Skills</h4><p>Required:<br>Strong verbal and written communication skills</p><p>Excellent organizational skills.</p><p>Must be a detail-oriented, collaborative and enthusiastic team player.&nbsp;</p><p>Strong ability to garner consensus on and support for new partnerships and initiatives, particularly when projects rely on participation by multiple internal or external stakeholders.&nbsp;</p><p>Ability to solve complex issues and identify creative solutions to assist members and community stakeholders.</p><p>Must have the ability to troubleshoot problem areas and recommend effective alternative solutions and provide optimal customer service for internal and external customers.</p><p>Demonstrates action oriented leadership to take on new opportunities and rewarding challenges with a sense of urgency, high energy, and enthusiasm.</p><p>Ability to multi-task and meet competing deadlines while maintaining attention to detail and accuracy.</p><p>Must be able to work independently or as part of a diverse team while being business-minded as well as empathetic towards members.</p><p>Must show initiative and act on anticipated business needs without prompting from management.<br><br>Ability to adapt quickly to a fast-changing environment.</p><p>Advanced proficiency in MS Office including Outlook, Word, Excel, and PowerPoint</p><p>Strong interpersonal skills and ability to read non-verbal cues with a high level of situational adaptability.</p><p>Ability to make sound decisions with incomplete information.</p><p>Preferred:<br>Experience with the Salesforce CRM platform</p><p>Knowledge and understanding of the unique needs of the Medi-Cal beneficiary populations within a social service, healthcare, not-for-profit, or government setting.&nbsp;</p><p>Knowledge of public agencies, organizations, and other resources that support Community Resource Center visitors.</p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.<br></p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p>Required:&nbsp;<br>Cardiopulmonary&nbsp;resuscitation (CPR) and California Mandated Reporter within 90 days-of-hire</p><p>Preferred:<br>Management of Aggressive Behavior (MOAB), de-escalation techniques training, safe lifiting practices training.</p><h4>Physical Requirements</h4>Moderate<h4>Additional Information</h4><p>Required:&nbsp;<br>Travel to offsite locations for work.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicare, Data Entry, Social Services, Medicaid, Relationship Manager, Healthcare, Administrative, Service, Customer Service                                                    </p>

Community Resource Center Specialist III

<p>Salary Range:&nbsp;&nbsp;$46,800.00&nbsp;(Min.) -&nbsp;$52,597.00&nbsp;(Mid.) -&nbsp;$62,270.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Quality and Population Health Coordinator I (QPHC) is responsible for outreaching to members to close care gaps. The QPHC also outreaches to providers for medical record pursuit and retrieval. The QPHC is an important member of L.A. Care’s quality improvement team, helping to drive improvement in health outcomes, population health, and health equity, as well as member and provider experience.</p><h4>Duties</h4><h4>Make outbound calls to members to assist with scheduling and coordinating services (e.g. appointments, lab tests, health screenings, other diagnostic studies, transportation, etc.). (25%)</h4><h4>Educate members on missing gaps in care. Encourage them to close care gaps and pursue preventative health and health promotion activities. (25%) </h4><h4>Outreach to providers to request medical reports by fax, electronic medical records, or on-site visits if needed. (15%) </h4><h4>Review medical records, claims, and encounter data to identify key information to help close gaps in care. (15%)</h4><h4>Provide support as needed for care gap closure campaigns and other quality improvement programs. (15%)</h4><p>Perform other duties as assigned. (5%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p>Required:</p><p>At least 3 months of experience following basic workflows, procedures, and standards related to patient or provider communication and outreach.</p><p>Previous experience working in an office setting with basic office equipment such as telephones, fax machines, computers, etc.</p><p>Preferred:</p><p>Health Plan, provider practice, or health education experience. </p><h4>Skills</h4><p>Required:</p><p>Demonstrates deep compassion and sensitivity towards patient needs and community well-being. </p><p>Driven by strong motivation to positively impact people’s lives.</p><p>Excellent verbal and written communication skills.</p><p>Excellent interpersonal skills.</p><p>Proficient with Microsoft Word, Excel, PowerPoint, and Outlook.</p><p>Skills in utilizing various online platforms and search engines to efficiently gather accurate and relevant information. </p><p>Highly organized with ability to maintain accurate notes and records.</p><p>Demonstrates high efficiency in managing tasks and consistently delivering projects to successful and reliable completion. </p><p>Ability to communicate effectively with patients and health care providers. </p><p>Preferred:</p><p>Some knowledge of HEDIS and other quality measures.</p><p>Some knowledge of quality improvement processes.</p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese&nbsp;&nbsp; </p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    EMR, Claims, Equity, Medical, Healthcare, Insurance, Finance                                                    </p>

Quality and Population Health Coordinator I (ALD)

<p>Salary Range:&nbsp;&nbsp;$102,183.00&nbsp;(Min.) -&nbsp;$132,838.00&nbsp;(Mid.) -&nbsp;$163,492.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Supervisor, Quality Configuration Assurance works with the Manager, Systems Configuration Performance Improvement and Director, Quality Configuration to oversee the daily operations of the Quality Configuration Assurance staff for the L.A. Care core and surround systems. &nbsp;This position is responsible to maintain a high performing team of Quality Configuration Assurance Analysts of various knowledge and technical skill levels by ensuring that each team member meets or exceeds all metrics and standards of quality. This position supervises all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.&nbsp;</p><p>The Supervisor, Quality Configuration Assurance engages, measures, and helps to facilitate improvements in the team's performance by conducting continual improvement activities such as training, coaching and quality assurance. This position will collaborate with the Quality Configuration Assurance leads to support new programs, system implementations and upgrades, quality measures to improve claims mass adjudication and configuration performance improvements, &nbsp;etc.</p><h4>Duties</h4><p>Responsible for the daily workflow and leading the work of assigned staff. &nbsp;This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. &nbsp;Hire, train, coach, and evaluate staff (under the guidance of the Manager, Systems Configuration Performance Improvement).&nbsp;</p><p>Maintain quality goals and production levels within the department. &nbsp;Develop procedure changes to improve results.</p><p>Track and trend the metrics associated with the systems configuration quality and production. &nbsp;Prepare and present written and verbal reports.</p><p>Maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet organizational requirements.</p><p>Serve as back-up for the Manager, Systems Configuration Performance Improvement and effectively interface with various personnel within and outside of the department and the organization. &nbsp;Collaborate timely and effectively with various internal and external staff to ensure the smooth execution of functions to support configuration best practices.</p><p>Assure the team completes related quality configuration work timely and in accordance with business requirements, testing methodologies, and systems specifications.</p><p>Provide direction with handling of questions, issues, etc. raised by staff. &nbsp; Serve as an informational resource for staff. &nbsp;</p><p>Lead and troubleshoot simple to moderate issues for the Quality Configuration Assurance Analysts and collaborate with the Quality Configuration Assurance leads on complex issues. &nbsp; Ensure that complex issues are resolved within established guidelines. &nbsp;Ensure that appropriate follow-through is completed timely.</p><p>Oversee and lead initiatives and projects. Ensure that tasks are completed within the specified timeframes.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business Administration or Healthcare Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:</p><p>At least 5 years of experience in a quality configuration supporting a managed care system, especially related to quality measures for benefit, contract configuration, and mass adjudication in a healthcare or health plan environment.</p><p>At least 2 years of leading process, program, or staff or supervisory experience.</p><p>Experience with the quality review of the configuration of health services/population health as well as appeals and grievances systems, applications, etc.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Preferred:</p><p>At least 5 years of experience working with a California Medi-Cal managed care plan or commercial health plan, medical group, or management services organization.</p><h4>Skills</h4><p>Required:</p><p>Advanced knowledge of QNXT or comparable claims processing system.</p><p>Advanced knowledge of the healthcare domain, focusing on claims processing, membership, contracts, and benefits.</p><p>Advanced knowledge of and experience with interpreting and analyzing complex pricing mechanisms.</p><p>Strong coaching and mentoring skills. Able to build teams and allocate staffing resources based on work priorities.</p><p>Strong written and verbal communication skills.</p><p>Proficient in using Microsoft Word and Excel.</p><p>Able to multi-task in a high production environment.</p><p>Able to streamline day-to-day operations, policies, and procedures.</p><p>Able to draw conclusions from data analysis and formulate corrective action plans, as warranted.&nbsp;&nbsp; </p><p>Able to troubleshoot problem areas and recommend, develop, and implement system and process improvements.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Insurance                                                    </p>

Supervisor, Quality Configuration Assurance

<p>Salary Range:&nbsp;&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Product Solutions Manager II is responsible for working within the Product Strategy, Sales and Marketing (PSSM) service area to identify and implement projects, programs and initiatives that support achievement of product and enterprise goals. The position works with management, business owners and other key stakeholders to develop and manage the product go to market planning, prioritization, timelines, metrics/scorecards, budgets, Return of Investment (ROI) analysis, and working agreements for product initiatives.&nbsp; </p><h4>Duties</h4><p>Develops, designs, and implements of cyclical product life, cycle activities and specific strategic initiatives in support of optimizing the member experience while managing the ongoing evolution and strategic direction of the product line.</p><p>Support efforts to identify product management best practices. Identify impacted parties, business partners, and resources required. Develops and designs processes and product requirements that support business needs. Designs methods for integrating function and processes including applicable dependencies inclusive of enterprise initiatives.</p><p>Conducts analysis for roadmap creation, scope and execution for cross-functional execution of initiatives.&nbsp; Recognizes opportunities for product enhancements in a matrix environment and collaborative, cross functional execution.</p><p>Orchestrates, plans and executes end to end cycle strategy, development and implementation efforts for the product line.</p><p>Identifies potential risks, project charge, and scope. Recommends in design of appropriate mitigation and contingency plans. Supports in&nbsp; identifying best practices to drive product integrity, service excellence, and efficiency.&nbsp;</p><p>Provides product support to internal and external stakeholders for annual product launch. Including, sales, marketing, growth and retention efforts, delegated vendors and front line teams including assistance with benefit trainings, explanation of benefit design, member materials development and distribution, sales and marketing collateral, talking points and&nbsp; program education, configuration and benefit display requirements. Develops training materials and conduct annual and ongoing product training as required.</p><p>Manages daily processes related to the end-to-end development and fulfillment of required annual materials&nbsp; for welcome and sales kits. Oversees process and timelines from model document population, regulatory approval, design/layout, translation, and print &amp; fulfillment. Responsible for review and accuracy of approved benefits on published materials.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Public Administration or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Administration or Related Field<h4>Experience</h4><p><br><strong>Required:</strong><br>Minimum of 5 years of relevant experience in product management.</p><h4>Skills</h4><p>Required:<br>Requires deep knowledge of product development life cycle (PDLC) discipline.</p><p>Must be familiar with regulatory guidelines governing product lines; leads regulatory filing process for new/custom product initiatives.</p><p>Able to use advanced features of MS Office including Excel, PowerPoint, Word, MS Project, Visio.</p><p>Excellent written and verbal communication and presentation skills.</p><p>Ability to serve as member on cross-functional implementation or project teams.</p><p>Ability to interpret data sets and forecast future revenue streams.</p><p>Excellent interpersonal, motivational, and communication skills; with success in leading cross functional collaborative projects.</p><p>Ability to collect, analyze and recommend solutions using data and experience driven decisions.</p><p>Working knowledge of the company’s healthcare products, functions and regulatory guidelines.</p><p>Working knowledge of policy and regulatory efforts.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Department Specifics:</p><p>Product, Strategy, Sales &amp; Marketing: (PSSM):&nbsp;</p><p>Preferred:&nbsp;<br>Knowledge of healthcare product types inclusive of managed care and insurance products.</p><p>Additional duties include:<br>Drives Intra-team development efforts for framework and delivery model ensuring alignment with Intra-team strategic goals and objectives set forward by CPO and Exec Owner. Supports and/or drive efforts for strategic planning on product agnostic initiatives as well as strategic partnerships.</p><p>Medicare:<br>Required<br>Medicare Advantage, with experience serving duals population. Direct experience in Medicare and Duals program administration including stars, quality, financial performance review, operational functions (claims, enrollment, readiness).</p><p>Preferred:<br>Direct experience with duals population and requirement.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicare, Claims, Healthcare, Insurance                                                    </p>

65 L.A. Care Health Plan Jobs