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<p>Salary Range:&nbsp;&nbsp;$47,840.00&nbsp;(Min.) -&nbsp;$57,062.00&nbsp;(Mid.) -&nbsp;$68,474.00&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 II supports in building relationships with members of the community, L.A. Care departments, and Blue Shield of California Promise Health Plan staff (under a collaborative partnership agreement), community based agencies, government agencies, and CRC vendors and instructors. The role supports community and provider communication and engagement initiatives to increase member traffic at a CRC and provides information to members of the community to physical and health education programs, classes and resources. Acts as a key partner to support the CRC marketing and promotional initiatives to meet operational needs. Follows workflows to refer members to receive services across L.A. Care departments that support a member's health care journey to promote positive health care outcomes. Helps connect members and community participants in understanding health care access issues, identifies resource needs based on social drivers resulting from member inquiries and health assessments, and refers to the appropriate source for subject matter assistance. Provides ongoing member assistance and follow-up in select cases. Works in partnership with L.A. Care health plan departments to provide customer service, social services support, care management, health education resources, behavioral health, member engagement marketing and communication, relies on line of business product knowledge and business insight. The CRCs serve anyone in the community in which they are located; and therefore, this role will provide support on referral processes to connect non-member cases to the appropriate external resources and collaborate with key stakeholders across L.A. Care in support of positive outcomes for members.</p><p>Supports the planning and development, implementation, and analysis of CRC services, programming, and vendor management. This role may support special projects following directions and instructions from a work plan, technical procedures, and relationship management ensuring successful implementation of CRC initiatives. </p><h4>Duties</h4><p>Day-to-Day Representation: (25%)<br>Supports the coordination of member-centric customer service to respond and resolve inquiries and questions and bridges members to appropriate resources. &nbsp;Provides guidance and support to inform, guide, and educate members, community residents, and other stakeholders regarding health education programs, benefit information, resources and support available at L.A. Care and partner health plan benefits, CRC resources to meet the member/visitor needs. Collaborates with team members to create resource guides and reference materials. &nbsp;Implements the appropriate approach to identify member or visitor resource needs in complex situations and takes action to link the member/visitor to the appropriate services, programs, or resources. Actively identifies gaps in CRC services, resources, and programs, delivers recommendations for new programs and proposes solutions for the implementation of new services. &nbsp;Participates in day-to-day work operations including opening and closing of the CRC, ordering and maintaining of office supplies, and inventory. Supports CRC vendors which deliver facility maintenance. Coordinates, maintains, and schedules CRC calendar and conference rooms, including management of appointments. Prepares conference/training rooms and assists with support services, as needed. Answers incoming calls in a timely and professional manner. &nbsp;</p><p>High-Touch Customer Focus: (25%)&nbsp;<br>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. Implements child development activities and programs to support children development while parents and guardians attend a class or service appointment at the CRC. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</p><p>Cross-Collaboration: (20%)<br>Supports community initiatives maintaining good relationships within L.A. Care and Blue Shield Promise Health Plan, and with community stakeholders to promote access to health care programs, classes, and preventative services offered at the CRC. &nbsp;Provides information to other L.A. Care departments on services and activities that resonate with and engage members of the CRC community based on hands-on experience at the Center.</p><p>Outreach and Engagement: (15%)</p><p>Supports and nurtures relationships with key internal and external stakeholders; and, is an ambassador to promote CRC partnership brand recognition. &nbsp;Establishes relationships with key community stakeholders, informs management on community needs, and enters data to inform an integrated approach to outreach activities and targeted member engagement. &nbsp;Supports planning, development, implementation, and analysis, of member and community engagement activities to increase member traffic at the supports outreach and engagement activities to attract new L.A. Care and partner health plan members into the CRC to participate in services and programs. Provides feedback to bridge members of the community to physical and health education programs and classes which will enhance health outcomes and member experience. &nbsp;Supports communications and marketing efforts through multiple platforms to increase member traffic at assigned CRC.</p><h4>Duties Continued</h4><p>Implementing Strategic Initiatives: (15%)<br>Supports the implementation of special projects which include identifying the scope of work responsibilities, accountabilities, deliverables, key milestones, timelines, and specific tasks that &nbsp;must be completed in order to ensure project, initiatives, and events are successfully implemented within the required timeframe.<br>Supports in monitoring risks and provides recommendations for management to implement mitigation plans to keep initiatives on-track. &nbsp;Collaborates in the maintenance of consistent documentation of project deliverables, tracks and reports project status. &nbsp;&nbsp;</p><p>Performs other duties as assigned. (10%)</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 6 months of community work focused on health care, public health, or health education, OR at least 6 months of operations work experience, community events, leading projects, and supporting relationships with multiple stakeholders.&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; &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; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br>Experience with data entry and reporting processes.&nbsp;</p><p>Preferred:<br>Previous experience in child development activities. &nbsp;</p><h4>Skills</h4><p>Required:<br>Ability to communicate verbally and in writing.</p><p>Organizational skills.</p><p>Detail-oriented, collaborative and enthusiastic team player.&nbsp;</p><p>Ability to assist with inquiries and identify creative solutions to assist members and community stakeholders.</p><p>Ability to troubleshoot problem areas and support effective alternative solutions and provide optimal customer service for internal and external customers.</p><p>Action oriented attitude 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>Ability to work independently or as part of a diverse team while applying business-insight as well as empathy towards members.</p><p>Initiative to act on anticipated business needs in the operational and customer service areas.<br><br>Ability to adapt quickly to a fast-changing environment.</p><p>Knowledge of MS Office including Outlook, Word, Excel, and PowerPoint</p><p>Excellent customer service skills.</p><p>Interpersonal skills, ability to read non-verbal cues and apply situational adaptability skills.</p><p>Ability to make sound decisions with incomplete information.</p><p>Preferred:<br>Experience with the Salesforce Customer Relationship Management (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.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p>Required:&nbsp;<br>Cardiopulmonary&nbsp;resuscitation &nbsp;(CPR) and California Mandated Reporter within 90 days-of-hire</p><p>Preferred:&nbsp;<br>Management of Aggressive Behavior (MOAB), de-escalation techniques training, safe lifting practices training.</p><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</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, Behavioral Health, Data Entry, Social Services, Public Health, Customer Service, Healthcare, Administrative, Service                                                    </p>

L.A. Care Health Plan

Community Resource Center Specialist II

<p>Salary Range:&nbsp;&nbsp;$164,614.00&nbsp;(Min.) -&nbsp;$222,230.00&nbsp;(Mid.) -&nbsp;$279,845.00&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 Associate Counsel III Senior Director Health Legal Services is responsible for diverse legal activities.&nbsp; This position provides analysis of health care regulatory matters and assisting with the development and review of legislative bills and administrative regulations.&nbsp; The Associate Counsel III reviews policies and procedures to ensure compliance with all legal authorities and confers with outside attorneys, state or county officials, and other interested parties.&nbsp; This position supports L.A. Care’s product lines and operations by providing substantive legal counseling on complex matters. This position provides non-supervisory guidance for staff counsel, paralegals, support personnel. This position reports directly to the Associate General Counsel, should the Associate General Counsel position be vacant, this position reports to the General Counsel. </p><p>The Associate Counsel III Senior Director Health Care Legal Services collaborates on the improvement of communication between the department and key stakeholders to define opportunities, identify and prioritize programs and projects based on predefined criteria (e.g. return on investment, productivity, compliance). Provides expert advice to various teams, including program and product development, marketing, and customer service, on various relevant topics.</p><h4>Duties</h4><p>Participates as a senior attorney member of the Legal Department’s Health Care Legal Services Unit (HCLS) supporting L.A. Care in a matrix management organizational structure by providing needed legal advice and counsel on the most complex and sensitive matters regarding various laws applicable to health care service plans, with an emphasis on California law.</p><p>Provides substantive counseling on complex provider contracting and other legal matters.</p><p>Manages outside counsel in connection with organization’s healthcare activities.</p><p>Provides significant effort for HCLS’s support of the provider and payer efforts.</p><p>Provides non-supervisory guidance for other HCLS staff.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</p><p>Interfaces directly with L.A. Care leadership and acting on behalf of the Associate General Counsel as needed.</p><p>Provides expert advice to various business units on relevant topics within the organizational standards, national and statewide compliance.</p><p>Evaluates the effectiveness of program implementation, and provides guidance and recommend process improvement. </p><p>Communicates strategic planning outcomes and the agreed upon priorities across the organization, to include ongoing progress of priorities. </p><h4>Duties Continued</h4><p>Leads efforts to allow the company to mitigate risk such as regulatory or competitive risks through innovative business ideas and solutions.</p><p>Responsible for communicating decisions, priorities and relevant project information to appropriate levels of staff regarding business unit requests and projects and initiatives.</p><p>Responsible for sharing solution roadmaps and enterprise level strategies to drive efficiencies across the organization and with customers. Collaborates with management to develop annual budgets for respective business areas.&nbsp; </p><p>Provides support in delivering programs that meet the compliance needs of the organization</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Juris Doctor Degree or Doctor of Law Degree (J.D.)<h4>Education Preferred</h4><h4>Experience</h4><p>Required:</p><p>Minimum of 6 years of experience as a practicing licensed attorney and has acted as senior counsel on legal projects and matters.</p><p>Experience in an HMO or as counsel to a health system, hospital, government unit, or a health care law firm practice.</p><p>Experience and knowledge of health care law.</p><p>Experience in supporting complex provider contracting activities including drafting and reviewing contracts, providing strategic advice regarding negotiations and operations on complex and sensitive matters.</p><p>Preferred:&nbsp; </p><p>Substantial experience in Medi-Cal or Medicaid and Knox-Keene Act.</p><p>Experience in Medicare, commercial lines of business and Health Insurance Portability and Accountability Act (HIPAA).</p><p>Supervisorial experience.</p><p>Experience in and knowledge of public entity laws including the Brown Act, Political Reform Act and Public Records Act.</p><h4>Skills</h4><p>Required:</p><p>Excellent interpersonal oral and written communication skills to facilitate open and clear dialogue with payers, regulators, providers, internal clients, contractors, vendors and L.A. Care leadership.</p><h4>Licenses/Certifications Required</h4>State Bar - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</p><p>Successfully passed California bar exam and maintains valid license/ certificate and be in good standing.</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>                    Medicaid, Medicare, Medical, Healthcare                                                    </p>

Associate Counsel III Senior Director Health Care Legal 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>PLEASE NOTE:&nbsp; The candidate selected for this position will work 3 p.m. to 11:30 p.m. PST, five days per week with rotating weekends and holidays.</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 Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews.</p><h4>Duties</h4><p><br>Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. &nbsp;Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%)</p><p>Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. &nbsp;Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%)</p><p>Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%)</p><p>Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%)</p><p>Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: &nbsp;Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%)</p><p><br>Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%)</p><p>Performs other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p>Required:<br>Minimum of 7 years of clinical experience in an acute hospital setting.&nbsp;</p><p>Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning.</p><p>Preferred:<br>Consistent Critical Care experience (Emergency Department, Intensive Care, Labor &amp; Delivery) background highly desirable.</p><p>Experience in bed placement decision-making highly desirable.</p><h4>Skills</h4><p>Required:<br>Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. &nbsp;</p><p>Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team &nbsp;</p><p>Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials.&nbsp;</p><p>Excellent time management and priority-setting skills.</p><p>Maintains strict member confidentiality and complies with all HIPAA requirements.</p><p>Strong verbal and written communication skills. &nbsp; &nbsp;</p><p>Preferred:<br>Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM.&nbsp;</p><p>Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4>Certified Case Manager (CCM)American Case Management Association (ACM)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:<br>Attend mandatory department trainings as scheduled</p><p>Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery.</p><p>Types of Shift: &nbsp;Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am).&nbsp;<br>Float (Varies)*<br>*All possible shifts.</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>                    Nursing, Registered Nurse, Rehabilitation, Therapy, Physical Therapy, Healthcare                                                    </p>

Utilization Management Admissions Liaison RN II (After Hours Evening)

<p>Salary Range:&nbsp;&nbsp;$60,778.00&nbsp;(Min.) -&nbsp;$75,950.00&nbsp;(Mid.) -&nbsp;$91,166.00&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><br>The Customer Solution Center Member Navigator II is responsible for resolving member inquiries. Coordination of care for complex cases which may involve benefit coordination, continuity of care, access to care, quality of care issues, member eligibility, assignment, disenrollment's issues and interpreting requests for all product lines (Medi-Cal, L.A. Care Covered, Cal MediConnect (CMC)). It will be expected that the main focus is to provide member satisfaction. In addition, this position is responsible for handling disenrollment's in coordination with U.M. department and Plan Partners: Department of Health Services (DHS), Centers for Medicare and Medicaid Services (CMS) National Committee Quality Assurance (NCQA) as well as L.A. Care guidelines. The Navigator ensures the proper handling of member issues whether presented by members, the Ombudsman's, state contractors, member advocates, Executive Community Advisory Committee (ECAC), L.A. Care Board Members or providers are resolved expeditiously. The Navigator handles and coordinates the identification, documentation, investigation and resolution of complex cases, in a timely and culturally-appropriate manner. Coordinates multi-departmental (Member Services, Product Network Operations (PNO), Claims, Utilization Management (UM), Pharmacy, Medicare Enrollment/Disenrollment, Sales and Quality Management (QM)) processes to ensure identification of member's claims of gaps in coverage and resolution of cases for members' satisfaction and of referral cases to plan partners when applicable. The Navigator will be stationed and available to assist our members at any of our designated Community Resource Center/Walk-In Center. Will provide Navigator support at other Community &nbsp;Resources Center locations as needed.</p><h4>Duties</h4><p>Coordinate multi-departmental (Member Services, PNO, Claims, UM, Sales, Medicare enrollment and QM) processes to resolve members 'issues and complex cases to the members' satisfaction. This process may include referrals to plan partners to ensure compliance with regulatory and L. A. Care guidelines. Ensure to follow departmental guidelines/matrixes for all processes. Urgent Complex cases will be handled within 24hrs. All others within 48hrs. (30%)</p><p>Work as a navigator to our Medicare Line Of Business (LOB): A. Ensure to meet deadline for completion of Welcome Calls; B. Ensure to follow through on all cases forwarded to other areas for assistance; C. Document all transportation services provided to each member. Ensure to confirm appointment and authorization; D. Coordinate/assist with all other departments regarding Medicare Services; E. Thorough Reinstatement of enrollment of members whose disenrollment are questionable; F. Identify and complete Organization and Coverage Determination for timeliness and resolution; G. Ensure proper Guidelines are followed for Medicare disenrollment request; H. Ensure to complete all BAE and/or LIS request. (25%)</p><p>Identify potential quality of care issues and referral to QM Department, through calls received from our Call Center and other internal customers. (10%)</p><p>Handle disenrollment's requests from members, providers and plan partners: 1) Long Term Care (Exhaustion of Benefits); 2) Move out of County; 3) Major Organ Transfers; 4) Incarceration; 5) Foster Care. (5%)</p><h4>Work with Compliance Department regarding suspected fraudulent activities received through the L.A. Care hot line and the Call Center personnel. (5%)</h4><h4>Communicate with collection agencies, billing business offices regarding delinquent and problematic member accounts which includes claims issues from L.A Care Medi-Cal Direct Program (MCLA), Healthy Families (HF), Healthy Kids (HK), and Special Needs Populations (SNP) members. (5%)</h4><h4>Work with Cultural &amp; Linguistic (C&amp;L) to provide translations for members' correspondence into the appropriate languages. As requested review documents submitted by C&amp;L to ensure proper translation and culturally sensitive materials for distribution to our members (brochures pamphlets and educational materials). (5%)</h4><h4>Meet general L.A. Care requirements for attendance and punctuality and follow department guidelines. (5%)</h4><p>Perform other duties as assigned. (10%)</p><h4>Duties Continued</h4><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><br>Required:</p><p>At least 2 years of experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and /or public services or public benefits programs with claims and Medicare experience.</p><p>Preferred:</p><p>Health Plan background a plus along with strong advocacy background.</p><h4>Skills</h4><p><br><strong>Required:</strong><br>Strong customer service skills.</p><p>Excellent oral and written communication skills.</p><p>Strong analytical and conflict resolutions skills as well as persuasion skills.&nbsp;</p><p>Proficient in MS Office applications, Word, Excel, Power Point, and Access.</p><p><strong>Preferred:&nbsp;</strong><br>Medical terminology a plus.</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.</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>                    Medicare, Claims, Call Center, Medicaid, Pharmacy, Healthcare, Insurance, Customer Service                                                    </p>

Customer Solution Center Member Navigator II (Location- Metro Los Angeles)

<p>Salary Range:&nbsp;&nbsp;$50,216.00&nbsp;(Min.) -&nbsp;$62,770.00&nbsp;(Mid.) -&nbsp;$75,324.00&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 Care Management Coordinator II is responsible for outreach to members/caregivers, providers, Community Based Organizations (CBO), and others to help enroll our highest need members into the Care Management (CM), and Disease Management (DM) programs. The position is responsible to assess member’s strengths, challenges, needs, and barriers to care through conducting telephonic Health Risk Assessment (HRA). The position works with the member/caregiver, Care Management Specialist, Community Health Worker, and the Interdisciplinary Care Team (ICT) to support the development and implementation of the care plan and address unmet needs. </p><p>This position coordinates the flow of information between the CM team and the member/caregiver, provider, medical group, and other members of the ICT. The position supports the coordination of member care as instructed by the Care Management Specialist and outlined in the care plan including the reinforcement of health education and disease management information; coordinating benefits such as transportation and DME; and linking member to community resources to address the Social Determinants of Health (SDoH) of the member. The position is responsible to ensure the CM team meets the contractual and regulatory requirements and timelines by maintaining accurate documentation and following up with the member and provider as needed.</p><p>In addition, this position is assigned projects to support the department in meeting its regulatory and contractual requirements, such as running reports, data validation, quality checks and other projects. The position assists with the communication and coordination between programs and maintains confidentiality when communicating member information.</p><h4>Duties</h4><p><br>Responsible for the time sensitive processes for initiating cases, managing referrals to the department, appropriate documentation, routing of information, performing computer data input, faxing, emailing, filing of confidential member information, and maintaining logs of activity, etc. (40%)&nbsp;</p><p>Engages members to participate in the CM/Disease Management programs by reaching out and promoting the programs to address member’s unmet needs. (10%)</p><p>Completes telephonic calls to conduct the HRA with high risk members participating in the CM program. Assists the care team with developing and assessing health interventions. (10%)</p><p>Conducts telephonic outreach calls to members/caregivers regularly and evaluates and documents their progress towards their healthcare goals. Consults and collaborates with the Care Management Specialist to set up provider/specialist appointments and follow up on treatment plans. (10%)</p><p>Handles the incoming and outgoing calls to members/caregivers and providers to coordinate care as identified in the care plan. (10%)</p><p>Initiates follow up calls to members to administer screenings or confirm linkage to appropriate resources. Provides general information to members and providers about the CM and DM programs. &nbsp;(10%)</p><p>Performs other duties as assigned. (10%)</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:<br>At least &nbsp;6 months of &nbsp;experience in an administrative and customer service role in a health care/health services setting .&nbsp;</p><p>Preferred: &nbsp;<br>1 year of Medical Assistant experience. &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; &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;&nbsp;<br>6 months of experience processing authorizations at a managed care/health plan setting.&nbsp;</p><h4>Skills</h4><p>Required:<br>Knowledge of medical terminology</p><p>Strong verbal and written communication skills</p><p>Proficiency in Microsoft Office with a high level of accuracy</p><p>Excellent organizational, and time management skills</p><p>Detail-oriented and a team player</p><p>Excellent customer service skills with compassion and empathy</p><p>Ability to demonstrate sensitivity and respect for the opinions, perspectives, customs, and individual differences of others.&nbsp;</p><p>Ability to value diversity of people and ideas, as well as interact &nbsp;with people from a wide range of backgrounds. &nbsp;</p><p>Ability to be &nbsp;flexible, open-minded, listen to and consider others’ viewpoints.&nbsp;</p><p>Ability to work well and develop effective relationships with diverse personalities.</p><p>Preferred:<br>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.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Medical Assistant (CMA)<h4>Required Training</h4><p>Preferred:<br>Motivation Interviewing&nbsp;</p><p>Trauma Informed Care</p><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>                    Medical Assistant, Public Health, Healthcare                                                    </p>

Care Management Coordinator II

<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 Lead Community Resource Center (CRC) is 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; The Lead will assist the CRC Manager with developing a successful and cohesive CRC team.</p><p>The CRCs serve anyone in the community in which they are located; and therefore, this role will additionally provide expertise on developing and monitoring effective referral processes to connect non-member cases to the appropriate external resources.&nbsp; The lead will monitor and assess the planning, development, implementation, and analysis of CRC services, programming, and vendor management.</p><p>The Lead will support manager with immediate urgent decisions for center operations as applicable if manager is not available.&nbsp; 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. </p><h4>Duties</h4><p>Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training and feedback on performance to department management.&nbsp; Oversees the daily office workflow, develops and recommends enhancements to process and procedures.&nbsp; 10%</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. 10%</p><p>Mentors and trains staff on special projects and processes that support the overall operation of the CRC to provide an excellent customer experience, represent the CRC brand, and implement innovative programs.&nbsp;&nbsp; Proactively monitors risks and provides recommendations and implements mitigation plans to keep initiatives on-track.&nbsp;&nbsp; Implements continuous process improvements to workflows, processes, and customer-centric support and member engagement are well as propose solutions for the implementation of new services. 10%</p><p>Oversees member-centric customer service to respond to a wide range of simple to complex inquiries and bridges members to appropriate resources.&nbsp; Monitors implementation of child development activities and programs to support children development while parents and guardians attend a class or service appointment at the CRC.&nbsp;&nbsp; 10%</p><p>Leads implementation of extended-hour schedule by providing operational support and demonstrated commitment to offering high quality in-person service supporting CRC staff working extended-hour schedules to support members and visitors that may need services outside of regular operating hours and days based on business needs. Escalates complex member/visitor or staffing issues to manager as appropriate. 10%</p><p>Create desk level procedures and provides extensive consultation on health care access issues and identification of resource needs based on social drivers identified through a health assessment process.&nbsp; Leads cross-functional collaboration with multiple L.A. Care health plan departments.&nbsp; Implements the coordination of member service support across L.A. Care departments to ensure accountability and promote positive health care outcomes. 10%</p><h4>Duties Continued</h4><p>Leads work plan development to define building, maintaining, and nurturing meaningful relationships with key internal and external stakeholders; and, monitors the growth of the CRC partnership brand recognition.&nbsp; 10%</p><p>Assesses partnership opportunities and identifies key community stakeholders, assesses community needs, and gathers and analyzes data to inform an integrated approach to outreach activities and targeted member engagement.&nbsp; Makes recommendations for bridging members of the community to physical and health education programs and classes that will enhance health outcomes and member experience.&nbsp;&nbsp; 5%</p><p>Provides support to the CRC management in developing strategies and tactics to implement community and provider outreach and engagement initiatives to increase member traffic at a CRC and bridge members of the community to classes and resources.&nbsp;&nbsp; Oversees the&nbsp; member engagement platforms by developing and implementing&nbsp; a strategy for CRC staff to act as a liaison to the L.A. Care departments that play a role on CRC-specific marketing, communications, and promotional initiatives to promote member and community engagement.&nbsp; 10%</p><p>Creates and leads community initiatives leveraging relationships within L.A. Care and Blue Shield Promise Health Plan and with community stakeholders to promote access to health care programs, classes, and preventative services offered at the CRC. 5%</p><p>Provides training and education to 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. 5%</p><p>Performs other duties as assigned.&nbsp; 5%</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:</p><p>A minimum of 4 years of experience in community events and leading projects focused on health care, public health, or health education.</p><p>At least 6 months of experience leading projects and/or staff, managing relationships with multiple stakeholders and have worked as a senior CRC Specialist.</p><p>Health care product experience including one of the following health care programs: Medicaid/Medi-Cal, Covered California, or Medicare Special Needs Plan.</p><p>Experience working cross-functionally with Care Management, Social Services, Health Education, and other social service or clinical teams.&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;&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;&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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Preferred: </p><p>Experience with Salesforce Customer Relationship Management (CRM) platform.</p><h4>Skills</h4><p>Required:</p><p>Strong verbal and written communication and presentation skills</p><p>Excellent organizational skills.</p><p>Must be a detail-oriented, collaborative and enthusiastic team player. </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. </p><p>Demonstrated ability to solve complex issues and identify creative solutions to assist members and community stakeholders.</p><p>Demonstrated ability to troubleshoot problem areas, recommend effective alternative solutions, and provide optimal customer service for internal and external customers.</p><p>Demonstrates action oriented leadership ability to take on new opportunities and rewarding challenges with a sense of urgency, high energy, and enthusiasm.</p><p>Strong ability to multi-task and meet competing deadlines while maintaining attention to detail and accuracy.</p><p>Strong ability to build effective teams with persuasive skills and ability to motivate others.</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>Ability to take initiative and act on anticipated business needs without prompting from management.</p><p>Exceptional customer service skills.</p><p>Strong 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:</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. </p><p>Knowledge of public agencies, organizations, and other resources that support Community Resource Center visitors.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Moderate<h4>Additional Information</h4><p>Required:<br>Requires walking, standing to a significant degree, dexterity of hands and fingers to operate a variety of standard office equipment. Requires sitting most of the time, but entails bending/ lifting, pushing and/or pulling of arm or leg controls. The job may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.)</p><p>Travel to offsite locations for work</p><p>Ability to work some evenings and weekends.</p><p>Preferred:</p><p>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&nbsp;&nbsp; </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>Job Segment: </strong>                    Relationship Manager, Public Health, Medicaid, Medicare, Social Services, Customer Service, Healthcare, Service                                                    </p>

Lead Community Resource Center

<p>Salary Range:&nbsp;&nbsp;$105,267.00&nbsp;(Min.) -&nbsp;$139,478.00&nbsp;(Mid.) -&nbsp;$173,689.00&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 Enterprise Architect Integration Engineer II is responsible for developing standards, tools and governance for capturing, storing and delivering enterprise data. This position is responsible to design and build L.A. Care's Data API work and/or SOA architecture. Working closely with the business, application and Information Technology (I.T.) infrastructure teams, the Enterprise Architect Integration Engineer II will analyze business and technical problems and develop the appropriate the framework to incorporate Master Data, event driven and batch processing entities to the Enterprise Data Management Cloud (EDMC) and/or master service bus.</p><h4>Duties</h4><p>Develop integration and architecture to meet the business needs of the company by working closely with key stakeholders and partners.</p><p>Integrate I.T. Solutions into a common framework. Enforce standards around systems technology stacks and mechanisms for governing cloud-based infrastructure.</p><p>Support in-house development teams to implement solutions. Responsible for providing technical and management guidance to all departments and works closely with development teams to ensure compliance. Supports the creation of roadmap documents, architectural documents, process documents, standards documents and governance documents. Collaborates with program-level architects across the organization on the details of the systems architecture for their particular domain.</p><p>Work closely with I.T. functional areas to identify and resolve integration and workflow considerations and issues. Responsible for assisting with the overall system design and architecture. Responsible for providing EA support to the Development department and Enterprise Architecture team. Work with other architects around business, data, systems, and security needs and how applications best participate in the overall enterprise architecture.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</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><h4>Experience</h4><p>Required:</p><p>At least 5 years of experience in design and implementation of data applications and integrations, using modern development tools, i.e. Java JSP applications or ORACLE/PL/SQL, or SQL Server Batch processes or similar technologies. </p><p>At least 5 years of experience designing and building solutions with SOAP, Rest API, Micro service development suites, i.e.&nbsp; Informatica IDMC/IICS, Mulesoft, or ORACLE SOA suite (ESB/BPEL/SOA/BAM).</p><p>Strong experience of managing advanced technical resources.</p><p>Demonstrated experience designing and building enterprise level canonical models.</p><p>Experience in multiple database platforms, including NoSQL, SQL Server and/or Oracle, Snowflake, Red Shift, Data Bricks, etc.</p><p>Experience working with end users to gather requirements and build technical solutions from concept to implementation.</p><p>Preferred:</p><p>Previous healthcare experience.</p><h4>Skills</h4><p>Required:</p><p>Strong understanding of process and queueing design patterns.</p><p>Strong problem-solving and analytical skills.</p><p>Excellent verbal and written communication skills with the ability to discuss and understand HealthCare business partners across all operations.&nbsp; </p><p>Must be well organized, flexible, motivated and enjoy the challenges of supporting a complex, changing environment, with attention to detail, at times under pressure, remaining flexible, proactive, resourceful and efficient. </p><p>Ability to build relationships throughout business units, our customers, and their teams to ensure that the services provided are of exceptional quality.</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><em>IT Enterprise Architecture:</em></p><p>Additional Duties and Responsibilities:</p><p>Develop Data Integration, API Integration and Application Integration architecture to meet the business needs of the company by working closely with key stakeholders and partners.</p><p>Integrate I.T. Solutions into the Enterprise Data Management Cloud framework.</p><p><em>IT Solutions Delivery:</em></p><p>Additional Duties and Responsibilities:</p><p>Develop SOA integration and Business Workflow architecture to meet the business needs of the company by working closely with key stakeholders and partners.</p><p>Integrate common SOA, BPEL, BAM, OSB, B2B, SQL, Core JAVA and Service Gateway Standards.</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                                                </p>

Enterprise Architect Integration Engineer II

<p>Salary Range:&nbsp;&nbsp;$47,840.00&nbsp;(Min.) -&nbsp;$57,062.00&nbsp;(Mid.) -&nbsp;$68,474.00&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 II supports in building relationships with members of the community, L.A. Care departments, and Blue Shield of California Promise Health Plan staff (under a collaborative partnership agreement), community based agencies, government agencies, and CRC vendors and instructors. The role supports community and provider communication and engagement initiatives to increase member traffic at a CRC and provides information to members of the community to physical and health education programs, classes and resources. Acts as a key partner to support the CRC marketing and promotional initiatives to meet operational needs. Follows workflows to refer members to receive services across L.A. Care departments that support a member's health care journey to promote positive health care outcomes. Helps connect members and community participants in understanding health care access issues, identifies resource needs based on social drivers resulting from member inquiries and health assessments, and refers to the appropriate source for subject matter assistance. Provides ongoing member assistance and follow-up in select cases. Works in partnership with L.A. Care health plan departments to provide customer service, social services support, care management, health education resources, behavioral health, member engagement marketing and communication, relies on line of business product knowledge and business insight. The CRCs serve anyone in the community in which they are located; and therefore, this role will provide support on referral processes to connect non-member cases to the appropriate external resources and collaborate with key stakeholders across L.A. Care in support of positive outcomes for members.</p><p>Supports the planning and development, implementation, and analysis of CRC services, programming, and vendor management. This role may support special projects following directions and instructions from a work plan, technical procedures, and relationship management ensuring successful implementation of CRC initiatives. </p><h4>Duties</h4><p>Day-to-Day Representation: (25%)<br>Supports the coordination of member-centric customer service to respond and resolve inquiries and questions and bridges members to appropriate resources. &nbsp;Provides guidance and support to inform, guide, and educate members, community residents, and other stakeholders regarding health education programs, benefit information, resources and support available at L.A. Care and partner health plan benefits, CRC resources to meet the member/visitor needs. Collaborates with team members to create resource guides and reference materials. &nbsp;Implements the appropriate approach to identify member or visitor resource needs in complex situations and takes action to link the member/visitor to the appropriate services, programs, or resources. Actively identifies gaps in CRC services, resources, and programs, delivers recommendations for new programs and proposes solutions for the implementation of new services. &nbsp;Participates in day-to-day work operations including opening and closing of the CRC, ordering and maintaining of office supplies, and inventory. Supports CRC vendors which deliver facility maintenance. Coordinates, maintains, and schedules CRC calendar and conference rooms, including management of appointments. Prepares conference/training rooms and assists with support services, as needed. Answers incoming calls in a timely and professional manner. &nbsp;</p><p>High-Touch Customer Focus: (25%)&nbsp;<br>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. Implements child development activities and programs to support children development while parents and guardians attend a class or service appointment at the CRC. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</p><p>Cross-Collaboration: (20%)<br>Supports community initiatives maintaining good relationships within L.A. Care and Blue Shield Promise Health Plan, and with community stakeholders to promote access to health care programs, classes, and preventative services offered at the CRC. &nbsp;Provides information to other L.A. Care departments on services and activities that resonate with and engage members of the CRC community based on hands-on experience at the Center.</p><p>Outreach and Engagement: (15%)</p><p>Supports and nurtures relationships with key internal and external stakeholders; and, is an ambassador to promote CRC partnership brand recognition. &nbsp;Establishes relationships with key community stakeholders, informs management on community needs, and enters data to inform an integrated approach to outreach activities and targeted member engagement. &nbsp;Supports planning, development, implementation, and analysis, of member and community engagement activities to increase member traffic at the supports outreach and engagement activities to attract new L.A. Care and partner health plan members into the CRC to participate in services and programs. Provides feedback to bridge members of the community to physical and health education programs and classes which will enhance health outcomes and member experience. &nbsp;Supports communications and marketing efforts through multiple platforms to increase member traffic at assigned CRC.</p><h4>Duties Continued</h4><p>Implementing Strategic Initiatives: (15%)<br>Supports the implementation of special projects which include identifying the scope of work responsibilities, accountabilities, deliverables, key milestones, timelines, and specific tasks that &nbsp;must be completed in order to ensure project, initiatives, and events are successfully implemented within the required timeframe.<br>Supports in monitoring risks and provides recommendations for management to implement mitigation plans to keep initiatives on-track. &nbsp;Collaborates in the maintenance of consistent documentation of project deliverables, tracks and reports project status. &nbsp;&nbsp;</p><p>Performs other duties as assigned. (10%)</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 6 months of community work focused on health care, public health, or health education, OR at least 6 months of operations work experience, community events, leading projects, and supporting relationships with multiple stakeholders.&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; &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; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br>Experience with data entry and reporting processes.&nbsp;</p><p>Preferred:<br>Previous experience in child development activities. &nbsp;</p><h4>Skills</h4><p>Required:<br>Ability to communicate verbally and in writing.</p><p>Organizational skills.</p><p>Detail-oriented, collaborative and enthusiastic team player.&nbsp;</p><p>Ability to assist with inquiries and identify creative solutions to assist members and community stakeholders.</p><p>Ability to troubleshoot problem areas and support effective alternative solutions and provide optimal customer service for internal and external customers.</p><p>Action oriented attitude 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>Ability to work independently or as part of a diverse team while applying business-insight as well as empathy towards members.</p><p>Initiative to act on anticipated business needs in the operational and customer service areas.<br><br>Ability to adapt quickly to a fast-changing environment.</p><p>Knowledge of MS Office including Outlook, Word, Excel, and PowerPoint</p><p>Excellent customer service skills.</p><p>Interpersonal skills, ability to read non-verbal cues and apply situational adaptability skills.</p><p>Ability to make sound decisions with incomplete information.</p><p>Preferred:<br>Experience with the Salesforce Customer Relationship Management (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.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p>Required:&nbsp;<br>Cardiopulmonary&nbsp;resuscitation &nbsp;(CPR) and California Mandated Reporter within 90 days-of-hire</p><p>Preferred:&nbsp;<br>Management of Aggressive Behavior (MOAB), de-escalation techniques training, safe lifting practices training.</p><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</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>Long Beach                                            <br><strong>Nearest Secondary Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Relationship Manager, Behavioral Health, Data Entry, Public Health, Social Services, Customer Service, Healthcare, Administrative, Service                                                    </p>

<p>Salary Range:&nbsp;&nbsp;$45,760.00&nbsp;(Min.) -&nbsp;$47,823.00&nbsp;(Mid.) -&nbsp;$55,818.00&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><br>The Claims Data Entry Clerk II is responsible for the accurate and timely data entry of claims and other documents, which includes: Keying claims for all lines of business, including complex claims. Data Entry of Claims in Core adjudication system. Checking the eligibility of members of services in order to sort claims by product. Scanning and sorting medical records. Reviewing claims for required information, returning claims to the provider when necessary. Preparing reports and ensuring that reports are accurate and generated within specified timeframes.</p><h4>Duties</h4><p>Creates and sends Rejection letters to the providers for the rejected Claims with 98.5% accuracy. Follows L.A. Care (LAC) policies and procedures. Keeps current with incoming daily receipts. Meets production standards. (50%)</p><p>Accurately sorts based on department procedures. Keeps current with incoming daily receipts. (25%)</p><p>Performs special projects and ad-hoc reporting as necessary. Projects are complete and reports are generated within the specific time frame agreed upon at the time of assignment. (15%)</p><p>Performs other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4><h4>Experience</h4><p>Required:<br>At least 6&nbsp;months&nbsp;of accurate, high-volume claims data entry or claims processing experience.</p><p>Preferred: <br>Managed care or Medi-Cal claims experience.</p><h4>Skills</h4><p><br>Proficient in Microsoft Office</p><p>Strong verbal and written communication skills</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><strong>Preferred:</strong><br>Claims Examiner Training</p><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>                    Data Entry, Claims, Clerical, Administrative, Insurance                                                    </p>

Claims Data Entry Clerk II

<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 Business Insights Data Analyst III is a key contributor responsible for supporting short and long-term operational and/or strategic business initiatives in the healthcare sector.&nbsp; This position navigates the complexities of healthcare data. This position encourages a dynamic and innovative mindset, emphasizing the importance of thinking outside the box.&nbsp; Independently navigates and analyzes data sources to derive meaningful insights. As part of the essential duties, this role involves extensive experience in data visualization, utilizing tools to translate complex datasets into visually compelling and easily understandable presentations. This position provides weaving narratives that communicate actionable insights to diverse stakeholders. </p><p>Furthermore, the Business Insights Data Analyst III collaborates in a highly matrixed environment with senior leaders, management, and line staff is essential. This position serves as a mentor to team members, leveraging analytics proficiency to drive successful outcomes. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Technical Excellence and Systematic Analysis: Completes work in a technical and systematic manner, applying standard formulas and methods prevalent in the healthcare industry.</p><p>Collects, manipulates, and analyzes data with precision, ensuring adherence to industry standards and relevance to current data trends.</p><p>Statistical Analysis and Modeling: Utilizes correlation analysis techniques to expose potential drivers in outcomes. Deploys statistical process controls to identify observations (e.g., providers, time-periods) which require additional special cause investigation. Determines and implements case-appropriate multivariate modeling techniques, such as basic regression and clustering.</p><p>Report Preparation and Visualization: Prepares detailed reports, utilizing a variety of visualizations such as graphs, charts, and dashboards effectively communicating significant results derived from data analysis. Collaborates with cross-functional teams to ensure reports align with business objectives and provide actionable insights.</p><p>Influential Communication and Project Leadership:&nbsp; Influences senior leadership, management, and line staff through compelling recommendations generated from data analysis. Drives initiatives to completion within a highly matrixed environment.</p><p>Adaptive Responsibilities: Conducts root cause analysis to identify underlying issues and drive effective solutions, leveraging data insights to address systemic problems. Adapts to evolving healthcare business and processes, demonstrating the ability to pivot and quickly learn new industry concepts and practices.</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>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Healthcare Analytics or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:<br>Minimum 4 years of collecting, manipulating, and analyzing data in business and/or healthcare</p><p>Minimum of 4 years of SQL experience, leveraging big data for complex analyses.</p><p>Extensive experience with data visualization using Tableau.</p><p>Proven experience in independently managing multiple priorities, including researching conflicting and/or inaccurate data to ensure data integrity and reliability.</p><p>Preferred<br>Experience in the healthcare industry.</p><h4>Skills</h4><p><br>Required<br>Proven hands-on experience with relational databases, including Oracle or SQL Server, and expertise in comprehensive data management and analytics platforms such as Cloudera.</p><p>Ability to articulate sophisticated analyses, trends, and strategic opportunities to clients and stakeholders through powerful data storytelling.</p><p>Strong interpersonal skills for effective engagement with management at various levels of the organization, including demonstrated ability to manage projects and initiatives.</p><p><br>Preferred<br>Strong proficiency in Python or R programming, showcasing the ability to harness advanced analytics and automation in data-driven initiatives.<br></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                                                </p>

65 L.A. Care Health Plan Jobs