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<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 ETL Data Integration Developer III is responsible for the operational support of Informatica environment including but not limited to automation, job scheduling, dependencies, monitoring and maintenance of Extract, Transform, and Load&nbsp;(ETL) mappings, mapplets, and documentation. This position manages, administers and works with ETL administration in addressing systems performance including on-going optimization and tuning of Informatica environment. This position develops reliable and complex ETL processes to support new development of the Enterprise Data Warehouse, Data Marts and other Business Intelligence projects. This position also assists the Data Warehouse team in completing current Data Warehouse initiative projects. This position also performs the duties to analyze and evaluate the data source and data targets required for the ETL mapping. Design, develop and implement complex ETL processes. This position also supports and participates in source data analysis, specifically as it relates to domain definitions. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Responsible for the operational support of Informatica environment including but not limited to automation, job scheduling, dependencies, monitoring, maintenance, patches, upgrades, security, and administration. </p><p>Administers systems performance including on-going optimization and tuning of Informatica environment. </p><p>Supports and enhances existing Informatica environment and develops new, complex ETL processes to support additional design, development and deployment of the Enterprise Data Warehouse, and Data Marts.</p><p>Assists data warehouse team in completing current data warehouse initiative projects.</p><p>Analyzes and evaluates data sources.</p><p>Designs and implements complex ETL processes.</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 Statistics or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Statistics<h4>Experience</h4><p>Required:<br>5 years of experience in Informatica ETL Developer role in Data Warehouse projects, Enterprise Data Warehouse, Online Analytical Processing (OLAP) and dimensional data modeling.</p><p>At least 3 years of proven development experience in design and development of ETL/Data Integration and Informatica Power Center Suite.</p><p>Experience with Erwin data modeling toolset.</p><p>Experience working in a PL-SQL environment.</p><p>Expert in database concepts, logical/physical design and development.</p><p>Strong experience and comprehensive proficiency with Informatica in an Oracle Data Warehouse/BI environment&nbsp;</p><p>Experience in documenting requirements and negotiating commitments&nbsp;</p><p>Strong project life cycle experience.&nbsp;</p><h4>Skills</h4><p>Required:<br>Strong database development skills including the ability to analyze, create and optimize complex SQL queries and stored procedures, working on relational databases especially Oracle &amp; MS SQL Server.</p><p>Proficient in data analysis and problem solving.</p><p>Possess excellent communication skills, both written and verbal.</p><p>Thorough knowledge of Systems Development Life Cycle (SDLC).</p><p>Must develop, foster and maintain an open, professional relationship with IT staff, management and business customers.</p><p>Excellent verbal and written communication skills.</p><p>Strong organizational and documentation skills.</p><p>Strong Understanding of DW/BI concepts.&nbsp;</p><p>Good knowledge of Software Development Lifecycle.</p><p>Understanding of development lifecycle methodology and ability to &nbsp;successfully deliver Informatica assignments.</p><p>Healthcare domain.</p><p>Proven ability to perform technology needs assessment and evaluate solution options.</p><p>The capability of performing interface analysis at the detail level.</p><p>A solid understanding of software development life cycle; and broad-based knowledge of application systems technologies.</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>

L.A. Care Health Plan

ETL Data Integration Developer III

<p>Salary Range:&nbsp;&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&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 of Clinical Quality Analytics (MSA) is responsible for the operations, projects and planning of the reporting and analytics on quality programs for all of L.A. Care’s line of business (LOB) which includes Medicare Stars, Exchange Quality Rating Systems and MediCal’s Managed Care Accountability Sets, and other data-sharing and/or quality improvement programs focused on enhancing member experience and quality of life. The MCQA is responsible for analyzing, monitoring, reporting, and providing technical collaboration and data driven decision making on clinical and operational quality improvement activities related to these programs. The MCQA recommends policies, and leads process improvement efforts. </p><p>Additionally, the MCQA works with the Quality Improvement team, department leadership, and the provider network on developing plan-wide quality improvement and data strategy activities. The MCQA assists in developing a long-term plan for analytics and evaluation activities to support the quality improvement strategy and goals, including enterprise wide data and analytics solutions. The MCQA manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct and indirect staff reports.</p><h4>Duties</h4><p>Leverage data to inform targeted strategies that indicate whom to engage, with what content and through which channel and frequency: prioritize members and providers based on characteristics, such as RAF scores, open care gaps and quality improvement performance to enable a targeted and tailored outreach for members and providers through preferred channels - web, print, email, etc.</p><p>Implement a data-driven quality improvement strategy and predictive model to prioritize a set of measures that will drive higher quality ratings. &nbsp;Evaluate measures on a regular schedule to accommodate quality improvement performance changes throughout the year. These insights will enable accountable entities to make in-flight adjustments as needed, throughout the measurement year. </p><p>Establish streamlined and accurate process for quality improvement performance scorecards at the contract, provider and member level along with predictive analytics models. Work closely with QPM, HIM and other analytics teams and vendors to ensure provider web based quality tools used to monitor performance and close diagnosis and care gaps are complete, accurate, and timely and provide actionable insights at the member level. </p><p>Develop meaningful dashboards, reports, tools, and presentations to inform and influence Stars strategy and related activities.</p><p>Act as an analytics and technical subject matter expert on teams working on development and execution of Stars strategic initiatives.</p><p>Work closely with Quality Improvement team to manage and lead quality reporting and analytical strategies to enable accountable entities and stakeholders to drive quality ratings improvement for CAHPS, HOS, HEDIS, Medication Adherence and Plan Operations</p><h4>Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.</h4><h4>Perform other duties as assigned.</h4><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Health or Health Informatics<h4>Experience</h4><p><br>Required:</p><p>At least 6 years of experience in HEDIS, quality improvement, risk adjustment analytics, research, or related work within a healthcare context.</p><p>At least 4 years leading staff or supervisory/management experience.</p><p>Experience working with complex data sets.</p><p>Experience with developing reports in Tableau, SQL and developing datasets and data marts.&nbsp; </p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p>Required:</p><p>Ability to effectively collaborate and support cross functional department leadership.</p><p>Strong understanding of health care quality reporting programs, specifically Medicare Stars and HEDIS and health plan regulatory reporting requirements.</p><p>High degree of initiative and motivation.</p><p>Strong understanding of best practices in data visualization including Tableau</p><p>Strong understanding of value-based payment concepts and related engagement strategies.</p><p>Knowledge of SQL coding.</p><p>Knowledge of managed care concepts and principles and basic health plan operations.</p><p>Excellent analytical, problem solving and decision-making skills.</p><p>Ability to manage multiple tasks and projects and to delegate.</p><p>Excellent reading, oral and written communication and interpersonal skills.</p><p>Ability to work independently.</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, Clinical Research, Medical Research, Public Health, Clinic, Healthcare                                                    </p>

Manager, Clinical Quality Analytics

<p>Salary Range:&nbsp;&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&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 Manager of Medical Management is responsible for the overall day-to-day operations of the staff and activities requiring clinical licensure in the Utilization Management (UM) department. This position will work closely leaders to develop and organize the department’s work priorities and deliverables. This position will manage clinical personnel to orchestrate and oversee the completion of tasks requiring clinical determinations. This position will also be responsible for internal and external reporting, and managing the monthly data needed to ensure department metrics are met or exceeded, including but not limited to, productivity, and satisfaction of internal and external customers.</p><p>The Manager of Medical Management will also work closely with other LA Care Leaders to ensure that work is being completed accurately and timely. This position will collaborate with interfacing departments to ensure that consistent application of clinical criteria, quality of work, and productivity is maximized. This position will also lead team meetings, develop the UM clinical staff, represent the UM Clinical unit at meetings when applicable, and escalate issues as appropriate. This position manages all aspects of running an efficient&nbsp; team, including hiring, supervising, coaching, training,&nbsp; disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements. Develops and implements approved departmental policies and procedures/workflows. Implements and monitors departmental performance standards.&nbsp; Performs ongoing monitoring and evaluation of departmental operations to assure optimal efficiency and effectiveness.</p><p>Collaborates with department leadership to establish operational objectives for the business unit.</p><p>Works with members of cross-functional teams to glean and provide information pertinent to operational goals and acts as an expert resource.</p><p>Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.</p><p>Ensures timely and accurate submission of reports/documents to organizational leaders and regulatory agencies.</p><p>Assures appropriate department interface with key internal and external stakeholders.</p><p>Participates in the development of and is responsible for the implementation of operational business plans and departmental objectives to support organization strategies.</p><p>Contributes to departmental statistical, quality and performance reports.</p><p>Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.</p><p>Provides input for the departmental budgets.</p><p>Leads various committees and workgroups.</p><p>Assures the maintenance of positive relationships with other departments, PPGs, other Local Initiatives and Community Based Organizations.</p><p>Implements, with approval, programs that improve the provision of services to members.</p><p>Manages content for PPG trainings/JOMS. Responsible for oversight and adequate performance of direct line of business PPG delegated activities. Work with department leadership for enhancements as necessary. Develops and sustains active communications with PPGs.</p><p>Provide administrative oversight of the L.A Care After Hours programs.</p><p>Actively participates in regulatory audits.</p><p>Performs other duties as assigned.&nbsp;&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in NursingIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><br>Required:</p><p>At least 6 years of clinical nursing experience.</p><p>At least 4 years of leading staff or supervisory/management experience.</p><p>Minimum of 3 years of relevant health plan 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>Preferred:</p><p>Experience with Medi-Cal, under-served and culturally diverse populations. </p><p>Experience with state Medi-Cal regulations.</p><p>Audit/oversight experience.</p><h4>Skills</h4><p><br>Required:<br>Excellent verbal and written communication skills.</p><p>Strong problem solving, planning, and organizational skills.</p><p>Ability to maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><br><strong>Required:</strong><br>Registered Nurse (RN)</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>                    Nursing, Registered Nurse, Medical, Healthcare                                                    </p>

Manager, Medical Management

<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 of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope.</p><p>This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership.</p><p>The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff.&nbsp; The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Ensures adequate/appropriate distributions of workforce, assignments and time off requests. &nbsp;Participates in the hiring and termination process providing recommendations with appropriate supporting documentation.</p><p>Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. &nbsp;Identifies, communicates and coaches to improve staff performance. &nbsp;Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. &nbsp;Completes intermittent and annual staff evaluations.</p><p>Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary.</p><p>Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals.</p><p>Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members.</p><p>Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department.</p><p>Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. &nbsp;Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. &nbsp;<br><br>Serves as a leader and role model as well as technical and informational resource for staff and peers.</p><h4>Duties Continued</h4><p>Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes.</p><p>Services as member/resource/liaison to the Interdisciplinary Care Team. &nbsp;</p><p>Recommends resources to improve performance standards in terms of Utilization Management. &nbsp;Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.</p><p>Participates on internal and external committees as delegated or assigned.</p><p>Serves as a consultant to other departments or organizations as needed.</p><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.</p><p>Performs other duties as assigned.</p><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 acute/clinical care experience.<br></p><p>Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. </p><p>Minimum of 3 years leading process, program, or staff or supervisory experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p>Required:<br>Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management.</p><p>Strong verbal and written communication skills.</p><p>Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.</p><p>Excellent organizational, time management, and interpersonal skills.</p><p>Must be detailed-oriented, energetic, and an enthusiastic team player.</p><p>Must be able to work independently.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - 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>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, Healthcare                                                    </p>

Supervisor, Utilization Management RN

<p>Salary Range:&nbsp;&nbsp;$206,311.00&nbsp;(Min.) -&nbsp;$278,520.00&nbsp;(Mid.) -&nbsp;$350,729.00&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 Medical Director, Community Health, acts as key medical leaders in the organization to help with the program development and oversight of Community Health.&nbsp; The Medical Director ensures that the programs align with our operational systems and tools while also performing utilization review of cases. </p><p>The Medical Director reports to the Senior Medical Director, Community Health. This position works closely with our Community Platform team as well as with the other cross-functional teams within L.A. Care (LAC). The Medical Director is responsible for supporting and ensuring that the development and implementation of Community Health protocols, policy and procedures align with regulatory and contractual requirements, internal core systems, workflows and processes. This position entails network development and relationship building with the community based organizations as well as supporting the oversight team when needed.&nbsp; The Medical Director collaborates, educates our delegated medical groups and plan partners (Anthem Blue Cross and Blue Shield/Promise), and ultimately helps to cascade the CalAIM referral process and eligibility criterial information down to our various provider networks.</p><h4>Duties</h4><p>Provide and oversee the delivery and quality assurance of prior and retrospective authorization processes for CalAIM Community Supports and related benefits, </p><p>Participate in the oversight, support and relationship management with our delegated medical groups and plan partners (Anthem Blue Cross, Care 1st and Kaiser). </p><p>Work closely with the Community Health team and the overall leadership and management accountability matrix as it relates to the program development and implementation. Share responsibility for the oversight and evaluation of the program.&nbsp; </p><p>Apply the necessary skills (clinical, operational, strategic, provider engagement) to ensure that the programs are successful for vulnerable eligible members and providers, and help ensure that the program and its participants meet the regulatory and contractual requirements as intended by CMS and California Department of Health Care Services (DHCS).&nbsp; </p><p>Perform utilization review of cases and participates in our care management programs periodically. </p><p>Provide utilization review and call coverage on scheduled weekends and holidays on a rotational basis.&nbsp;</p><p>Perform utilization reviews and determinations; and address grievance and appeals, and State Fair Hearings and periodically attend the inter-disciplinary case conferences with our Care Management teams.&nbsp;</p><p>Collaborate with hospitals, Federally Qualified Health Centers, primary care practices, and the L.A. County Departments of Health Services, Mental Health, Public Health and community-based organizations and other key partners. Conducts virtual and on-site visits with our community partners when needed. </p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Doctor of Medicine (M.D.)<h4>Education Preferred</h4><h4>Experience</h4><p>Required:<br>At least 8 years of clinical medicine experience after medical school.</p><p>Demonstrated experience working in a collaborative or matrix relationship</p><p>Experience in maintaining liaison with Federal, State, and local bodies and medical organizations.</p><p>Preferred:</p><p>Physicians with social service experience in governmental programs, social service organizations (e.g. homeless or supportive housing), justice-involved, diversion and re-entry programs and/or other non-health care related organizations. &nbsp;</p><p>Experience with working for underserved, safety net populations including those who are homeless, persons with disabilities, seniors, foster children and youths and those of various ethnic and cultural backgrounds.</p><p>Demonstrated history working with community groups and organizations.&nbsp; &nbsp;</p><p>Demonstrated experience in developing and implementing and/or evaluating programs, policies and procedures.<br></p><h4>Skills</h4><p>Required:</p><p>Demonstrated ability to provide leadership to physicians, nurses, and other health care and non-health care professionals, and an interest and involvement in the affairs of the health care and social service communities.&nbsp; </p><p>Demonstrated ability for teamwork and collaborative problem solving. </p><p>Demonstrated strong analytic ability. </p><p>Excellent written and verbal communication skills, negotiating skills, consensus building and teamwork, planning and implementation skills.</p><p>Demonstrated ability in public relations including effectiveness in working with community groups and organizations.</p><p>Understanding and knowledge of homelessness, social determinants of health, children with complex medical conditions, justice-involved populations who have significant clinical needs, and the growing age population.</p><h4>Licenses/Certifications Required</h4>Board Certified, preferably in a primary or medical specialty - 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>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>                    Public Health, Medical, Relationship Manager, Counseling, Healthcare, Customer Service                                                    </p>

Medical Director, Community Health

<p>Salary Range:&nbsp;&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&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 Director, Care Management &nbsp;will mainly be responsible for the operational component of the Care Management (CM) Department with the main goal of improving key L.A. Care members healthy and access appropriate services. The Director will also work with the CM Medical Directors and key staff in designing, enhancing and implementing programs, plan strategically and report on regulatory requirements. &nbsp;&nbsp;</p><p>One of the key initiatives is to increase our community CM presence. The Director is also responsible for providing evidence of ongoing compliance with all regulatory and accreditation requirements (i.e. health risk assessments and interdisciplinary care plan and care team programs, population health management. The Director is also responsible for outreaching and working with key stakeholders and provide subject matter expertise in support of the oversight, outreach and training of our Plan Partner Health Plans and Delegated Provider Groups.</p><p>This position will direct all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>General Essential functions:&nbsp;<br>Collaborating with the Medical Director, responsible for the operations, programming and oversight of internal L.A. Care’s Care Management Department, collaborates with internal and external delegates and any operations associated with the Care Management department. &nbsp;Functions currently include all care management programs (Complex Care Management, Care Coordination and Disease Management). &nbsp;</p><p>Ensures the CM department performs the following: &nbsp;</p><p>All contracts [(i.e. Centers for Medicare and Medicaid Service (CMS), California Department of Health Care Services (DHCS)], California Department of Managed Health Care (DMHC) regulations, applicable state and federal regulations, National Committee on Quality Assurance (NCQA) CM Certification, Management Services Agreements &amp; Other Contracts. &nbsp;</p><p>Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements. &nbsp;</p><p>Assures department meets all regulatory time frames on CM.</p><p>Develops and implements departmental policies and procedures. &nbsp;</p><p>Develops and maintains departmental statistical and performance reports. &nbsp;</p><p>Develops, implements and monitors performance standards.</p><p>Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.</p><p>Develop and maintain departmental budgets in line with organizational goals. &nbsp;Assure operational effectiveness to meet MCR targets and optimize health care resource utilization.&nbsp;</p><p>Assures appropriate staff support of Utilization Management and other relevant committees. &nbsp;</p><p>Supports the maintenance of positive relationships between L.A. Care and external groups.</p><p>Identifies and implements, with approval, programs that improve the provision of services to members. &nbsp;</p><p>Supports Clinical Assurance/Delegation Oversight in the measurement and analysis of delegated Participating Physician Group (PPG) functions.</p><h4>Duties Continued</h4><p>Internal Health Plan Operational Management:&nbsp;<br>Proactively identifies and implements operational modifications to enhance departmental performance. &nbsp;</p><p>Develops and implements operational business plans and departmental objectives to support organization strategies and tactics. &nbsp;</p><p>Interfaces with and collaborates with other service areas to assure optimal service delivery to members, compliance, and efficiency. Maintain compliance with all internal audits.</p><p>Human Resource Management:&nbsp;<br>Develops 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.</p><p>Develops and maintains a culturally sensitive work environment that promotes staff growth and education.&nbsp;</p><p><br>Completes performance appraisals in accordance with established policies and based upon achievement of the L.A. Care mission, value, objectives and management expectations.&nbsp;</p><p>Assures staff have access to appropriate training and educational opportunities.</p><p>Oversees development of staff planning, including recruitment and retention.</p><p>Data System Development and Data Analysis:<br>Directs oversight and responsible for identifying and developing business needs for complex ongoing data projects and communicating with I.T. team on business needs.&nbsp;</p><p>Assesses and revises program goals and staff training based on data analysis and review.&nbsp;</p><p>Responsible for the Policies, Procedures, Budget and Program Documentation.</p><p>Develops and regularly reviews and maintains Care Management program documents to be in compliance with all regulatory and accreditation requirements and to be in line with current program activities. Prepares briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's &nbsp;regulatory position and policy. &nbsp;Develop regulatory position and policy based on research and evidence.</p><p>Vendor Management and Oversight:<br>Oversees existing contracts invoice processing, budget maintenance and compliance with contract’s scope of work.</p><p>Assesses and evaluates contract extensions and development of new vendor contract partnerships in alliance with enterprise–wide and departmental goals, objectives and members’ needs to achieve quality healthcare services and improves members’ quality of life.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Nursing<h4>Education Preferred</h4>Master's Degree in NursingIn lieu of degree, equivalent education and/or experience may be considered.<h4>Experience</h4><p>Required:</p><p>Minimum of 7 years of Care Management experience including progressively responsible leadership experience facilitating quality/process improvement, updating policies/procedures with the latest regulatory and accreditation standards.&nbsp; </p><p>At least 5 years of leading staff or supervisory/management experience</p><p>Minimum of 3 years of relevant Health Plan experience.</p><h4>Skills</h4><p><strong>Required:</strong><br>Excellent verbal, written and presentation skills.</p><p>Critical thinking skills.</p><p>Ability to efficiently and effectively assimilate information and communicate clearly and promptly to key stakeholders.</p><p>Ability to analyze and identify trends in reports to facilitate decision for enhancements to program.</p><p>Proven effective leadership skills.</p><p>Proficient with MS Office (Word, Excel, Outlook, PowerPoint, etc.)</p><p>Motivational interviewing skills.</p><p>Knowledge of compliance standards in the operational function.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Licensed Master of Social Worker (LMSW) - Active, current and unrestricted California LicenseRegistered Nurse (RN) - Active, current and unrestricted California License<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>                    Nursing, Registered Nurse, Social Worker, Medicaid, Medicare, Healthcare, Service                                                    </p>

Director, Care Management

<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 Information Technology Vendor Management Specialist II supports all procurement activities across the Information Technology (IT) department. Works in collaboration with various departments and vendors in creating, managing, reviewing contract items, and managing IT related contracts end-to-end through L.A. Care's contracts process, including Contract Requests, Master Agreements, Statements of Work, Requisitions, Orders, Non-disclosure Agreements, and other items as required. Assists IT Management by interacting with vendors to obtain price quotations for software license and support renewals and other items as necessary. Tracks the creation of and expenditures against IT Purchase Orders. Maintains records in L.A. Care's contract management system, which includes all vendor contract and billing related information. Supplies up to date status on contracts and invoices for status reports.</p><h4>Duties</h4><p>Participates in all aspects of IT contract development, approval, implementation and administration for L.A. Care. Coordinates, tracks, and escalates IT related contacts through the contracts process in collaboration with IT Management, business customers, vendors and legal services. Understands contract structure to identify financial terms, rates and commitments. (25%)</p><p>Works closely with Finance, vendors and L.A. Care management to ensure appropriate invoicing and payment in compliance with contract terms and rates. Tracks paid/unpaid invoices for status reporting and follow-up actions. (25%)&nbsp;&nbsp;&nbsp; </p><p>Conducts research on and analysis of various issues pertaining to Purchase Orders and Purchase Requisitions through resolution and payment processing. (25%)</p><p>Reviews and certifies price quotations, facilitates legal contract review when necessary and coordinates with vendors on the creation and use of Purchase Orders. (15%)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Performs 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>Required:</p><p>A minimum of 4 years of experience with general Information Technology functions and organization.</p><p>Preferred:&nbsp; </p><p>Experience in all aspects of contract origination, contract management, invoice verification and payment.</p><p>Ariba systems experience. </p><h4>Skills</h4><p>Required:</p><p>Careful attention to detail and accuracy for calculations and tracking of dollars, rates, contract terms, cost centers, other details of contracts, invoices, purchase orders, price quotations, orders, and other items.</p><p>Strong interpersonal skills to be able to work with a diverse group of staff and management individuals with various demands and objectives, in person, via email, chat, phone, and remotely as necessary to accomplish the objectives of the group.</p><p>Ability to organize contract work to get new contract items in place quickly. Prepare and process amendments ahead of expiration dates and other deadlines.</p><p>Ability to organize invoice processing to meet objectives for on time and early pay discount objectives.</p><p>Ability to work effectively under deadline pressure in order to move high priority contract and payment items to conclusion.</p><p>Preferred:</p><p>Proficient in a medium to advance level in Excel, including PivotTables. </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>

Information Technology Vendor Management Specialist II

<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 of Appeals and Grievances Clinical Operations (A&amp;G) RN is responsible for executing the day-to-day clinical operations of the A&amp;G department, and monitoring the A&amp;G RN staff responsibilities and activities. This includes, but is not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolutions within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Appeals &amp; Grievances and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope.</p><p>This position is responsible for assisting with and development and maintenance of a successful and cohesive unit, with a high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the A&amp;G department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A Care's culturally diverse membership.</p><p>The position supports the A&amp;G Clinical Manager. This role also assists the A&amp;G Leadership in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of A&amp;G staff.&nbsp; The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Ensures adequate/appropriate distributions of workforce, assignments and time off requests.&nbsp; Participates in the hiring and termination process providing recommendations with appropriate supporting documentation.</p><p>Monitors staff’s performance including productivity and compliance with regulatory requirements, compliance with policies.&nbsp; Identifies, communicates and coaches to improve staff performance.&nbsp; Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the A&amp;G team. Completes intermittent and annual staff evaluations.</p><p>Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary.</p><p>Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals.</p><p>Plans and oversees A&amp;G clinical activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members.</p><h4>Duties Continued</h4><p>Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department.</p><p>Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs.&nbsp; Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines.&nbsp; </p><p>Serves as a leader and role model as well as technical and informational resource for staff and peers.</p><h4>Fosters a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes.</h4><h4>Serves as a member/resource/liaison to the A&amp;G Operations Team.</h4><h4>Recommends resources to improve performance standards in terms of Appeals &amp; Grievances.&nbsp; Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.</h4><h4>Participates on internal and external committees as delegated or assigned.</h4><h4>Serves as a consultant to other departments or organizations as needed.</h4><h4>Performs other duties as assigned.</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p>Required:</p><p>Minimum of 8 years of acute/clinical care experience.</p><p>Minimum of 2 years of experience in RN clinical operations in an acute care or health plan setting.</p><p>Minimum of 2 years in a lead/supervisory experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p>Required:</p><p>Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality.</p><p>Strong verbal and written communication skills.</p><p>Computer literacy with proficiency in Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.</p><p>Excellent organizational, time management, and interpersonal skills.</p><p>Must be detailed-oriented, energetic, and an enthusiastic team player.</p><p>Must be able to work independently.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - 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>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>                    Nursing, Registered Nurse, Clinical Research, Medical Research, Clinic, Healthcare                                                    </p>

Supervisor, Appeals and Grievances Clinical Operations RN

<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 Facility Site Review (FSR) Nurse Specialist RN II conducts Full Scope Reviews, Site Review Surveys, Medical Record Review Surveys, Specialty Site Review Surveys, physical accessibility review survey (PARS) assessments, Focused Reviews, Interim Onsite Reviews, Consultation/Educational Site visits, Investigative visits, and/or other appropriate site visits to ensure quality FSR and physician compliance with Local, State, and Federal requirements.&nbsp; The FSR Nurse Specialist RN II may also conduct face-to-face visits with our high-membership physicians to provide feedback, data, and education on programs and facilitates changes to improve quality of care and service to members.</p><h4>Duties</h4><p>Conducts audits utilizing Department of Health Care Services (DHCS) FSR/MRR/PARS tools.&nbsp; Provides pre-audit and /or post audit educational sessions. Issue Corrective Action Plans (CAPs) and provide assistance or follow up in implementing adequate correction(s) on-site. </p><p>Gives providers health education materials and clinical tools to facilitate improved screening, preventive care, and chronic disease management; promote clinical quality improvements in practices.</p><p>Acts as the Provider Quality Improvement Liaison (PQIL) to assess and communicate issues and improvement opportunities identified during the physician site visit.</p><p>Communicates and coordinates information and findings from site visits between FSR Manager, internal and external staff and provider sites.&nbsp; Documents discussions and correspondence in FSR file as appropriate.</p><p>Assists and participates in the Annual Audit of Plan Partners delegated for FSR.</p><p>Perform other duties as assigned.</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:</p><p>At least 5 years of clinical experience including, but not limited to Emergency Room (ER)/Acute care nursing or outpatient setting.</p><p>Preferred:&nbsp; </p><p>Medi-Cal managed-care auditing experience.</p><p>At least one (1) year experience in Quality Improvement and/or familiar with DHCS audit tool.</p><h4>Skills</h4><p>Required:<br>Excellent verbal and written communication skills.</p><p>Excellent organizational and time-management skills.</p><p>Proficient in Microsoft Office.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California LicenseMust obtain and maintain successful completion of a DHCS Certified Site Reviewer certification in order to conduct DHCS accepted audits independently within 8 months of date of hire in the position.<h4>Licenses/Certifications Preferred</h4>Department of Health Care Services (DHCS) Certified Site Reviewer<h4>Required Training</h4><p>1:1 on-site and/or virtual training with Certified Site Reviewers (CSRs) until certification is obtained. Minimum of 8 months.&nbsp; </p><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</p><p>Travel to offsite locations for work.</p><p>Travel is required 80% of time.</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>

Facility Site Review Nurse Specialist RN II

<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 Customer Solution Center (CSC) Representative II has advanced knowledge of healthcare and various managed care product lines, including Medi-Cal, PASC, L.A. Care Covered/Cal Medi-Connect and is proficient in medical terminology. The position responsibilities include duties such as: assist supporting queues and management with projects as needed (e.g. provide informative feedback on desktop procedures, follow-up on member inquiries, CSC Representative shadowing etc.), acting as back-up support to Call Center Leads. This position handles inbound and outbound interactions involving member eligibility verification, general provider inquiries, claim status (pre-payment), &nbsp;general program and administration questions for all lines of business including direct member request for I.D cards and Primary Care Physician (PCP) changes, triages calls to appropriate units or outside entities and processes payments for L.A. Care Covered members. All interactions are documented in system of record.</p><h4>Duties</h4><p><br>Answers incoming calls for all product lines from members, potential members, providers and advocates. Handles and resolves member issues, assists members in connecting with internal units or external parties such as Plan Partners, Primary Care Physician (PCP) offices, pharmacists, etc. Provides essential information to members regarding access to care issues, coordination of care issues, benefits, Evidence of Coverage (EOC), Member Handbook, etc. Assists providers in using the Interactive Voice Response (IVR) web portal and verifying member eligibility. Documents all calls via the member data base systems. (QMEIS). Ensures department compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations relating to protection of personal history information. Troubleshoots and directs calls to the appropriate departments or outside entities. (60%)</p><p>Processes payments for L.A. Care Covered members. (15%)&nbsp;</p><p>Supports robocall and ad-hoc member outreach activities as determined by business need. (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 1 year of customer service call center experience in a healthcare environment.&nbsp;</p><p>Data entry experience with ability to type a minimum of 40 wpm.&nbsp;</p><p>Ability to answer a high volume of calls; previous ACD experience preferred.&nbsp;</p><p>Preferred: &nbsp;<br>Managed care or health plan experience.</p><h4>Skills</h4><p>Required:<br>Knowledge of medical terminology.</p><p>Good understanding of service to the disadvantaged population, seniors and or people with chronic conditions or disabilities.&nbsp;</p><p>Must be a quick learner, excellent team player and customer service oriented.&nbsp;</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><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>L.A. Care Health Plan Call Center is available 24 hours a day, 7 days a week, including holidays. Call Center work shifts are assigned based on business need and may include, but not be limited to, evenings, weekends and holidays.</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>

65 L.A. Care Health Plan Jobs