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<p>Salary Range:&nbsp;&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p><br>The Claims Supervisor works with the Claims Manager to oversee the daily operations of the claims department. This position is responsible for ensuring that quality levels of performance are maintained throughout the Claims Department and that all functions remain in compliance with State and Federal regulations. This position will &nbsp;manage new program implementations and/or system implementations. This position must maintain an up-to date knowledge of national and state-wide standards and regulations pertaining to claims processes and will ensure that production standards meet quality guidelines are met throughout the department ensuring the Plan’s compliance. This position will work with &nbsp;department Supervisors and staff to develop procedures ensuring the achievement of goals and will continuously monitor the work performed within the Department.</p><p>The position supervises all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.&nbsp;</p><h4>Duties</h4><p>Provide an environment that allows staff members to flourish in their work duties. Quality levels of 99% maintained throughout the department. Continuous training of supervisors on supervisory responsibilities as well as staff training on all enhancements and updates to claims regulations and company policies. Develop procedure changes to improve results. Corrective action plans developed and implemented to remediate any shortcomings in goal achievement.</p><p>Maintain quality goals and production levels within the Department. Ensure that Claims Department Supervisors are working effectively with their staff to ensure quality and production goals associated with each work area are consistently met by staff during their regularly scheduled work hours.</p><p>Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care.</p><p>Track and trend the metrics associated with the claims adjudication. Prepare and present written and verbal reports. Research complex problem areas within the department or within the systems used by department, and identify the root cause of these issues and recommend corrective actions.</p><p>Supervise 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>Perform other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business or Healthcare Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business or Healthcare Related Field<h4>Experience</h4><p>Required:</p><p>At least 3 years of experience as claims examiner working with medical facility claims and high dollar claims.</p><p>At least 2 years of 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><p>Experienced in working with Provider Dispute Resolution (PDR's). </p><p>Must have extensive experience in handling claims appeals with experience in communicating with external providers.</p><h4>Skills</h4><p>Required:<br>Sound understanding of health care code sets including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10 and revenue codes required. &nbsp;</p><p>Familiarity with Diagnosis Related Group (DRG) pricing.</p><p>Ability to multi-task in a high production environment.&nbsp;</p><p>Familiarity in working with and interpreting Provider and facility contracts and &nbsp;LOA's and MOU's. &nbsp; &nbsp;&nbsp;</p><p>Ability to draw conclusions from data analysis and to formulate corrective action plans when necessary. &nbsp;&nbsp;</p><p>Proficient in using Microsoft &nbsp;Word and Excel.&nbsp;</p><p>Must have strong coaching and mentoring skills and have the ability to build effective teams. &nbsp;</p><p>Must have excellent written and verbal communication skills with ability to work effectively with diverse team members.&nbsp;</p><p>Ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Insurance                                                    </p>

L.A. Care Health Plan

Supervisor, Claims

<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, Analytics is responsible for planning and managing the activities of a team of seasoned analysts that provide reports, insights, and analytics to L.A. Care’s enterprise reporting and analytics needs.</p><p>The Manager is responsible for developing the analytics solutions that meet the customer needs and deliver actionable insights to Enterprise Risk Adjustment and Encounters (ERAE) and Finance leadership, as well as to L.A. Care executive leaders.</p><p>This position is responsible for supporting Encounters and Risk Adjustment programs through the metric and key performance indicator (KPI) development, data modeling, investigative analytics, reporting, implementation, and coordination of initiatives and operational programs.&nbsp; This position is the primary contact for encounter data and reporting to the Encounter Governance Committee (EGC).</p><p>The Manager is responsible for identifying, addressing, socializing and championing efforts to fix issue impacting encounter data cleanliness.&nbsp; This position will develop and maintain relationships with key stakeholders across the enterprise to increase transparency to encounter data and the encounter process and access and appropriately use the most critical, actionable data to achieve their objectives.</p><p>This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.</p><h4>Duties</h4><p>Manage multiple tasks, adapt to change, and meet project deadlines in a dynamic environment</p><p>Design, produce, quality review, and support cross-functional teams in analytics to populate dashboards and KPI reports.&nbsp; Manages and develops interventions to reconcile encounter submissions to minimize errors and data loss and perform root cause analysis.&nbsp; Supports the performance of investigative analytics and root cause analysis in support of improving performance outcomes</p><p>Identify patterns and emerging trends based on aggregate data to find risks or opportunities and make performance change recommendations.</p><p>Work with key internal stakeholders to share important information and increase company awareness of relevant data.&nbsp; Collaborates with key internal stakeholders to update, track, and report KPI for all Risk Adjustment programs and processes through reporting and dashboard development.&nbsp; </p><p>Develops and maintains quality controls and validation reporting for relevant Risk Adjustment activities, submissions, and reports.&nbsp; Prepares presentations, reports, process documentation, for internal and external stakeholders to support successful programmatic outcomes.</p><p>Acts as a resource for other members of the department on technical issues and identify ways to leverage technology, processes, and tools to solution for desired program outcomes.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</p><h4>Duties Continued</h4><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.</p><p>Develop goals, objectives and actions plans for assigned staff. </p><p>Lead the analytics and reconciliation team and ensure that all team members have the resources and support the need to meet objectives and succeed.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Data Analytics or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Data Analytics or Related Field<h4>Experience</h4><p>Required:</p><p>At least 6 or more years of experience in data analysis and information reporting.</p><p>At least 4 or more years of experience leading, supervising or managing staff.</p><p>3 or more years of interaction with Enterprise Data Warehouses (EDW).</p><p>3 or more years of individual contributor experience performing analysis on healthcare data (especially encounters).</p><p>Preferred:</p><p>Experience with Risk Adjustment methodologies.</p><p>Experience with claims, clinical, and/or financial data.</p><p>Experience with clinical documentation, medical records, and electronic medical record systems.</p><p>Analytics experience in management, actuarial/healthcare economics, risk adjustment and quality improvement programs.&nbsp; </p><p>Analytics experience with Medicare Advantage, Medicare Fee-For-Service (FFS), Multipurpose Senior Services&nbsp;Program (MSSP) and Accountable Care Organization (ACO) programs, and commercial populations.</p><h4>Skills</h4><p>Required:</p><p>Understand and demonstrated ability to develop metrics used by regulators to monitor encounter and risk adjustment performance.</p><p>Understand and demonstrated ability to develop key performance indicators (KPI) and performance metrics </p><p>Proven ability to analyze and identify performance drivers as well as present key insights to management.</p><p>Proficiency in communicating analytic insights for stakeholder consumption in formats such as Tableau, Power BI, or other relevant tools.</p><p>Proficient skills on SQL, Python, R, SAS, SPSS</p><p>Experience in working with large, complex, disparate data sets</p><p>Experience with data interpretation, analysis, visualization, and reporting</p><p>Advanced level MS Excel for data analysis</p><p>Excellent verbal and written communication skills</p><p>Excellent presentation skills</p><p>Preferred:</p><p>Knowledge of managed care and health care claims</p><p>Knowledge of Risk Adjustment models (e.g. CMS Medicare Advantage, HHS-HCC, Medicaid DxCG)</p><p>Extensive knowledge of healthcare industry, Medicare Advantage, and Traditional Medicare</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    EMR, Medicare, Claims, Accounting, Medicaid, Healthcare, Insurance, Finance                                                    </p>

Manager, Analytics

<p>Salary Range:&nbsp;&nbsp;$55,245.00&nbsp;(Min.) -&nbsp;$69,045.00&nbsp;(Mid.) -&nbsp;$82,867.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p><br>The Lead Customer Solution Center Service Representative is responsible for the development of a successful and cohesive Call Center unit, with a high level of productivity to achieve the department's overall performance metrics, and to meet and/or exceed member satisfaction. Assist Call Center Supervisors with the supervision of Member Services Representatives by closely monitoring performance, which includes but not limited to: coaching, mentoring, motivating, counseling, etc. to ensure they are providing optimal customer services and meeting and/or exceeding department goals.&nbsp;Responsible for the daily workflow and leading the work of assigned staff.</p><h4>Duties</h4><p>Leadership of day to day activities of Member Services Representatives, including but not limited to: Providing direction. Monitoring of staff performance including attendance. Handling all questions/issues raised by staff. Recommending process improvement processes. Preparing and analyzing call center statistical reports. Monitoring/Adjusting of skill-sets for consistency. Ensuring quantity/quality is met for overtime. Handle escalated calls. Back-up to calls as needed. Assist Supervisor to ensure that Representatives provide accurate, timely and quality service to our members/providers. Ensure that all departmental policies, procedures and standards are being met, as well as the organization's mission. Assist Supervisor to ensure that deviations in performance are identified in advance and process changes are made to redirect performance to acceptable levels. Assist Supervisor to ensure that we provide accurate, timely and professionally written, statistical and verbal reports to management for historical, current status and forecasting purposes. Assist Supervisor in reviewing the Representatives overall quality accuracy. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. (40%)</p><p>Trains and motivates staff. Ensures appropriate service standards are developed and maintained. 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;&nbsp; (5%)</p><p>Work with training staff to ensure that training practices support staffing and performance standards, takes responsibility for identifying on-going training needs and integrating training and performance expectations as well as work closely with Supervisors to create and/or modify Desk top procedures. (5%)</p><p>Work closely with management to review performance and quality standards on an ongoing basis and to assist with development and implementing incentive programs. As well as motivational programs needed to achieve service standards. (10%)</p><p>Ensures that front line service personnel are capturing information and providing feedback to Supervisors that will enable L.A. Care to improve its product and internal process. (10%)</p><h4>Duties Continued</h4><h4>Represents the Department when requested at meetings. Assist Supervisor with meetings and provides necessary feedback when requested. (5%)</h4><h4>Ensure department remains in compliant with HIPAA regulations relating to protected health information (PHI). (10%)</h4><h4>Maintains attendance expectations. (5%)</h4><h4>Perform other duties as assigned. (10%)</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p>Required:</p><p>At least 2 years of customer service experience.</p><p>At least 6 months of lead experience in a health plan/ healthcare customer service call center environment.</p><p>Preferred:</p><p>Experience in working with the disadvantage population, Covered California, and Cal MediConnect.</p><h4>Skills</h4><p>Required:<br>Must have knowledge in direct line of business.&nbsp;<br><br>Must know Medical Terminology.</p><p>Must have excellent written and verbal communication skills.</p><p>Strong analytical, coaching/mentoring skills, team building.<br><br>Ability to work effectively with diverse team members.<br><br>Must also have the ability to troubleshoot problem areas and recommend effective alternative solutions to handle irate callers, and provide optimal customer service for internal and external customers.</p><p>Must be flexible with time and be able to work overtime including weekends.&nbsp;</p><p>Must be able to multitask and to streamline day to day operations, policies and procedures.</p><p>Must have advance PC skills including Excel and Access.</p><p>Preferred:<br>Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>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>                    Call Center Representative, Customer Service Representative, Call Center, Customer Service                                                    </p>

Lead Customer Solution Center Service Representative

<p>Salary Range:&nbsp;&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p><br>The Product Solutions Specialist II is focused on providing end to end development and management for product line initiatives. This position is focused on applying&nbsp; technical healthcare contract expertise in performing in the development and management of product line initiatives.&nbsp; This position&nbsp; supports contract-related inquiries, initiatives, and projects that support the overall product strategy and lifecycle. Works closely with leadership and participate in cross functional groups.</p><h4>Duties</h4><p>Responsible for identifying&nbsp; product management best practices,. Identify impacted parties, business partners, and resources required. Collaborate and support in implementing best practices cross functionally.</p><p>Recommend and participate in the design of processes and product requirements that support business needs. Designs methods for integrating function and processes including applicable dependencies inclusive of enterprise initiatives.</p><p>Identify risk and help troubleshoot resolution of issues.</p><p>Participate in the Product Development Lifecycle and or initiatives through the management of contracts and regulatory filings.</p><p>Collaborate with leadership to develop the regulatory filing schedule for cycle documents.</p><p>Prepare and ensure regulatory filing documents according to timeline.</p><p>Support all product contracts regarding benefits, quality performance measures, penalty risks, etc.&nbsp; Monitoring of the tactics for compliance/contractual requirements.</p><p>Develop the technical product requirements according to contractual obligations to ensure compliance.</p><p>Facilitate the coordination of responses from partners for ad-hoc requests and develops responses according to established timeline.</p><p>Facilitate effective cross-functional meetings to adequately support new strategic implementations.</p><p>Primary contact for technical requirements, development and execution.</p><p>Develop a sustainable and repeatable process for the technical adaptation and validation of product initiative.</p><p>Evaluate and support the remediation efforts of member grievance or plan partners.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><br>Required:</p><p>At least 3 years of Commercial Medicare/Medi-Cal Product Experience (Product &amp; Benefit knowledge) and of California Health Insurance Exchange (Covered CA)/Centers for Medicare and Medicaid Services (CMS)/Department of Health Care Services (DHCS) requirements experience.</p><h4>Skills</h4><p>Required:<br>Knowledge of product strategy.</p><p>Knowledge of product management and strategic planning and packaging concepts.</p><p>Ability to conclude and recommend using data and experience driven decisions. &nbsp;</p><p>Ability to make decisions to drive towards and accomplish team objectives. &nbsp;</p><p>Strategic thinking skills and ability to create messaging to influence desired outcomes.</p><p>Ability to anticipate future demands of initiatives related to people, technology, budget and business within your department and design/implement solutions to meet these needs.</p><p>Able to communicate results and business impacts to stakeholders within and outside of the company</p><p>Ability to partner in the ingestion, consumption and distribution of information from regulators with potential impacts on product.&nbsp;</p><p>Ability to effectively work closely with project team leaders and under the guidance of leadership.&nbsp;</p><p>Strong skills in MS suite - Word, Power Point, Visio, Project.</p><p>Strong knowledge of Department of Managed Health Care (DMHC), Covered CA, Centers for Medicare and Medicaid Services (CMS), and DHCS contractual requirements.</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>Medicare:</p><p>Preferred:&nbsp; </p><p>Experience in Health Care with Commercial products specifically in Qualified Health Plan (QHP) and/or Benefits related definition and requirements for LA Care Covered (LACC), L.A. Care Covered Direct (LACCD), PASAC lines of business. </p><p>Medi-Cal Plan Partners:&nbsp;&nbsp; </p><p>Required:</p><p>Experience serving Medi-Cal population. Skilled in building relationships with external partners. Service oriented. Skilled in resolving conflict.</p><p>Preferred:</p><p>Understanding of Medi-Cal managed care model, eligibility requirements, benefits, enrollment processes, and regulatory requirements governing Medi-Cal managed care plans. Understanding of managed care principles and operations.</p><p>Medi-Cal:</p><p>Required:</p><p>Experience working in Medi-Cal managed care and serving the Medi-Cal population. Knowledge of Medi-Cal regulatory requirements and program guidelines.</p><p>Commercial Product:</p><p>Required:</p><p>At least 3 years of Commercial regulatory filing experience (e.g. DMHC).</p><p>Strong Adobe Analytics and other analytics tools skills.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicare, Medicaid, Healthcare                                                    </p>

Product Solutions Specialist 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 Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.</p><h4>Duties</h4><p>Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.</p><p>Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. </p><p>Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.</p><p>Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.</p><p>Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. </p><p>Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner.</p><h4>Perform other duties as assigned. </h4><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>At least 5 years of varied clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting .&nbsp;</p><p>Preferred:<br>Managed Care experience performing UM and CM at a medical group or management services organization.</p><p>Experience with Managed Medi-Cal, Medicare, and commercial lines of business.</p><h4>Skills</h4><p>Required:<br>Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. &nbsp;Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate &nbsp;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>Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team &nbsp;<br><br>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 Care Management (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)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>May work on occasional weekends and some holidays depending on business needs.</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, Medicare, Medicaid, Claims, Healthcare, Insurance                                                    </p>

Utilization Management Nurse Specialist RN 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 Program Manager III oversees multiple complex programs in the department.&nbsp; This position designs and manages the implementation, operations, and the evaluation of strategic programs or functions of the assigned program of responsibility.</p><p>The position strategizes implements and maintains program initiatives that adhere to the department’s goals.&nbsp; </p><p>Acts as a Subject Matter Expert, (SME) serves as a resource and mentor for other staff.&nbsp; </p><h4>Duties</h4><p>Aligns program goals with the organizational strategy.&nbsp; Defines and maintains standards for program management within the department. </p><p>Develop program goals and objectives. Ensure team members have the resources needed to meet their objectives.&nbsp;&nbsp; .</p><p>Responsible for defining the metrics, quality standards, and documentation required for consistent project management and execution across the business</p><p>Serves as SME for all programmatic processes and procedures.&nbsp; Provide strategic direction to program start-up and closeout activities including development, and refinement of program management tools, resources, and processes.</p><p>Directly responsible for the financial management of assigned programs including the development, tracking, and updating of budgets; monitoring monthly projections and actuals; obligated funds notifications; budget modifications and other financial matters.</p><p>Designs and orchestrates the delivery of applicable communication to staff and management to establish goals and strategies related to the program.</p><p>Oversee the development and implementation of annual work plans, ensuring timely and high-quality reviews and submissions.</p><p>Collaborates with key stakeholders on program implementation and facilitate communications with cross-functional departments on the status of ongoing activities, manage compliance to scope and reporting requirements.&nbsp; Ensure approval from management are in place.</p><p>Provides recommendations and guidelines on strategic business development, including the identification and pursuit of new business opportunities, and technical assistance to support full cycle program development</p><h4>Duties Continued</h4><p>Manage and troubleshoot issues, including but not limited to cross-functional team relations, financial, and regulatory compliance, reporting and documentation.</p><p>Applies subject matter 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 program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Related Field<h4>Education Preferred</h4>Master's Degree in Related Field<h4>Experience</h4><p>At least 5 years of strong program management experience with large and complex programs.</p><p>Experience performing problem solving, policy, and/or program implementation.</p><p>Experience in overseeing program/project teams</p><h4>Skills</h4><p>Required:</p><p>Strong ability to build strong relationship management with a diverse set of partners</p><p>Ability to convey complex information, listen actively, and negotiate effectively.</p><p>Strong skills in strategic thinking.</p><p>Ability to Identify and analyze issues, and devise effective solutions.</p><p>Demonstrated ability to Stay open to change and continuously learn.</p><p>Understand the wider objectives of the program, such as business and strategic goals.</p><p>Strong knowledge of budgeting and resource allocation procedures.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Program Management Professional (PgMP)Lean Six SigmaManaging Successful Programmes (MSP)<h4>Required Training</h4><h4>Physical Requirements</h4><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>                    Relationship Manager, Customer Service                                                    </p>

Compliance Program Manager III

<p>Salary Range:&nbsp;&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Compliance Advisor II ensures L.A. Care business units are compliant with all Product Lines' contractual, state and federal regulatory, and accreditation requirements. The Compliance Advisor develops regulatory submissions, reports, agendas and communications to the Internal Compliance Committee and the Compliance and Quality Committee of the Board of Governors and provides support for the management of external state and federal regulatory audits. The Compliance Advisor prepares executive summaries and reports, develops and conducts training activities for subordinates, peers and L.A. Care business units and participates in interdisciplinary/cross-functional teams. </p><p>The Compliance Advisor may investigate, assist with coordination and management of teams and workgroups, project documentation and workflows, draft and complete presentations, auditing and monitoring of performance standards, and other duties as assigned. Although the Compliance Advisor's primary responsibility is providing support and for the Regulatory Compliance unit, the Advisor also advises and supports the Manager, Director, and Chief Compliance Officer on other duties as assigned to support the mission and responsibilities of the Compliance Department and to support the business operations of L.A. Care Health Plan. </p><h4>Duties</h4><p>Analyze and interpret contractual, state and federal regulatory, and accreditation requirements.</p><p>Participate in and conduct compliance functions, including, but not limited to, developing compliance tools and validating implementation of new requirements and corrective action plans.</p><p>Work with internal business units to prepare reports for distribution to internal Committees and external entities.</p><p>Facilitate cross-functional teams including internal business units and/or external entities to correct performance deficiencies.</p><p>Prepare and conduct trainings for internal business units and/or external entities.</p><p>Review, approve and suggest revisions on policies and procedures, member/provider materials, compliance work plans, etc., as well as submit to regulatory entities for approval.</p><p>Work with internal business units to identify gaps, develop and implement corrective action plans and facilitate monitoring activities to ensure compliance with regulatory requirements.&nbsp;</p><p>Review internal and external inquiries and collaborate with all levels of organizational management, business units and our Delegates to ensure timely, accurate, and complete submissions. This includes self-disclosures of non-compliance issues to the regulators.</p><p>Develop, maintain, and monitor Internal Compliance Committee (ICC) Charter, Compliance Program and&nbsp; key performance indicators. Responsible for the development of Board/committee write-ups to be presented at the Compliance &amp; Quality (C&amp;Q) and Internal Compliance Committee (ICC) meetings.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Public Health 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 Related Field<h4>Experience</h4><p>Required:</p><p>At least 3 years of experience in a managed care setting. </p><p>Experience in health care auditing and monitoring (preferably in Appeals, Grievances, Quality Improvement, Utilization Management (UM) and so forth) and developing audit tools.</p><p>Demonstrated experience developing and delivering training programs and making presentations.</p><p>Preferred:</p><p>2 years of Medi-Cal, Medicare or commercial product compliance. Regulatory change management and risk management experience and/or business continuity experience in a health plan or hospital setting preferred.&nbsp; </p><h4>Skills</h4><p><br>Required:<br>Excellent written and verbal communication skills.</p><p>Knowledge in health care compliance.</p><p><br>Ability to manage multiple priorities and projects and meet deadlines.&nbsp;</p><p>Knowledge of Medi-Cal Managed Care principles and/or government programs.</p><p>Persuasion Skills: 1. Ensuring organizational compliance with all state and federal Medi-Cal Program requirements reduces L.A. Care's risk to state/federal sanctions and fines- communicate required action to senior management/Board of Governor (BoG), Plan Partner staff. 2. Internal audit program and internal reviews&nbsp; are indicators of the quality of health care services provided to L.A. Care Medi-Cal members.&nbsp; This serves to help maintain a quality and solvent provider network and avert provider network disruptions due to poor quality of care and/or insolvent providers. All areas of risk/noncompliance are to be identified, reported and monitored.</p><p>Working knowledge of California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and Knox-Keene requirements, as well as highly developed analytical and critical thinking skills, to serve as a resource to internal business units and external entities.</p><p>Preferred:<br>Advanced skills in Visio, PowerPoint and/or SharePoint preferred.&nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Public Health, Risk Management, Internal Audit, Medicare, Medicaid, Healthcare, Finance                                                    </p>

Compliance Advisor II

<p>Salary Range:&nbsp;&nbsp;$55,245.00&nbsp;(Min.) -&nbsp;$69,045.00&nbsp;(Mid.) -&nbsp;$82,867.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Customer Solution Center Quality Auditor (QA) II is responsible for monitoring and actively influencing the Customer Solution Call Center team’s quality performance, ensuring that the quality requirements in place are fulfilled and the goals are consistently achieved. This position will analyze quality results and performance in order to identify and optimize processes and support staff development, in partnership with the Quality Assurance Management. This position will identify processes, situations, and opportunities where improvement is needed and be responsible for creating performance reports and action plans. The position will maintain a high level of based knowledge on benefits for all product lines (Medi-Cal, CMC, PASC, Healthy Kids and Covered California) as well as serve and act as the department's SME (Subject Matter Expert). This position will assist in the development of tools and procedures established to audit each vertical under the Customer Solution Center. In addition, this position will make recommendations for individual and group training/retraining and process improvements. This position will assist in the development of training materials delivered to various internal departments and off site Call Center vendor to measure product knowledge. As needed, this position will be assisting and conducting training for new onboarding QA staff and assist and support trainers with academy classes. &nbsp;</p><h4>Duties</h4><p><br>Conduct audits to ensure that regulatory and quality requirements were met across all verticals under CSC. Conducts random member audits and surveys to ensure the member experience has a positive outcome. Responsible for monitoring call center, including Call Center Leads, Outbound and Outreach, Ansafone, Web Inquiries, M.R.U. (Member Relations Unit), and Appeals and Grievance, performance against key performance indicators and recognizes trends that require individual or group retraining. Conducts/reviews audits and analyzes the data and documentation and provides their input to management for review. Tracks and trends daily error reports, analyze results from Call Center, MRP, Medicare, M.R.U., Outbound and Outreach, and L.A. Care Covered scorecards and recommend quality improvements for the CSC Department. Create and assist in developing Desk Level Procedures (DLP) for all supporting units. (65%)</p><p>Performs and assist with weekly calibrations. Assists with new hire training (CSC and QA) and/or up training, assess class curriculum, Desk Level Procedures (DPL), and recommend changes as necessary. Compiles quality data on a daily/monthly basis to measure compliance with internal policies and procedures as well as regulatory requirements. Reviews quality reports, outcomes, recommends corrective action plans as needed and reports irregularities or vulnerabilities to appropriate parties as deemed necessary. &nbsp;Frequently compiles quality data to measure compliance as well as regulatory requirements. Review quality reports, outcomes, recommend corrective action plans as needed and report irregularities or vulnerabilities to appropriate parties as deemed necessary. &nbsp;(15%)</p><p>Provides 1:1 Coaching Assessments to all pertinent departments. Consistently participates in quality initiatives and special project task forces as deemed necessary. Works with unit managers to develop quality tools to monitor potential departmental vulnerabilities (Membership Accounting, Call Center Unit, Outbound and Outreach, and Member Relations Unit). Provides unit managers and departmental director with analysis on the error trends and provide recommendations for improvements. Serves as the subject matter expert for all Lines of Business (Medi-Cal, CMC, PASC/SEIU, Healthy Kids, L.A. Care Covered...); in addition to programs used at L.A. Care: MHC, MEIS, QNXT, QMEIS, IVR, NICE, MEDACCESS, TTY, SALESFORECE, MEDIASENSE, CISCO FINESSE, WEX CALLBACK and RETRO Process, AEVS, IHSS Website, and Provider Search Oracle. Reviews targeted audit text documentation (MIU, CC, MRP and Member Relations) and update quality screens via NICE/Access/MHC/MEIS/QMEIS software. The QA is also responsible for assisting Call Center with call intake as needed. (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><br>Required:</p><p>At least 2 years of quality assurance experience preferably in healthcare's Member Services or Quality Assurance. </p><p>Knowledge of and experience of Medi-Cal, Medicare, and Covered California.</p><h4>Skills</h4><p><br>Required:<br>Good oral and written communication skills.&nbsp;</p><p>Strong analytical skills, excellent technical skills and attention to detail.&nbsp;</p><p>Excellent technical skill.</p><p>Strong research skills.</p><p>Intermediate knowledge of MS Office.</p><p>Ability to coach and train employees.</p><p>Working knowledge of a CRM, AEVS, and other benefit eligibility programs.</p><p><br>Preferred:<br>Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>American Society for Quality - Certified Quality Auditor (ASQ - CQA) Certification<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, Call Center, Audit, Healthcare, Customer Service, Finance                                                    </p>

Customer Solution Center Quality Auditor 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 Clinical Quality Program Manager is responsible for identifying, implementing, and guiding projects relating to quality excellence in Centers for Medicare and Medicaid Services (CMS) Five-Star Rating System and Marketplace Exchange Quality Rating Systems (QRS). The position is responsible for strategizing quality improvement programs and ongoing management using a data-driven focus that sets priorities for improvements aligned with ongoing strategic initiatives. This position collaborates with the Quality Improvement/ Quality Performance Management QI/QPM and Health Information Management (HIM) analytics support, Risk Adjustment, other plan operations business units, and network providers to strategize and promote success in achieving L.A. Care's enterprise wide quality goals and initiatives. </p><p>The Clinical Quality Program Manager develops and tracks the work plans, identifies and implements short and long-term intervention and programs that support goals to improve quality program ratings, provides oversight in the deployment and evaluates the effectiveness. This role also tracks, manages, and reports project progress and outcomes. Manage vendor contracts. Facilitates collaboration with internal and external stakeholders to ensure the full integration of initiatives throughout the organization.</p><p>The Clinical Quality Program Manager is a subject matter expert (SME) on Clinical Quality programs, interventions and quality metrics related to Medicare Stars or Covered California QRS programs.&nbsp; These programs include metrics that support Consumer Assessment of Healthcare Providers and Systems (CAHPS) and / or Health Outcome Survey (HOS) and /or Healthcare Effectiveness Data and Information Set (HEDIS), Medication Adherence and Plan Operations and /or other domains of focus such as Pharmacy and /or Administrative / Regulatory.&nbsp; </p><p>Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Develop and maintain clinical quality work plans, convene committees and workgroups, and assist. Leads the Core Teams by leveraging technology and tools to streamline processes, enhance collaboration and synergy, promote data sharing, and improve transparency across clinical and operational areas.</p><p>Drive collaboration, education, training, and maintaining working relationships across the Core teams with multiple departments throughout LAC including but not limited to QI, Pharmacy, Care Management, Utilization Management, Risk Adjustment, Products, Customer Solution Center (CSC), reporting and Analytics, Appeals and Grievances and the provider network.</p><p>Manage and maintain the SharePoint sites to ensure all guidance from regulatory entities are available to key stakeholders and that enterprise-wide activities are documented and shared among accountable entities and network providers.</p><p>Coordinate workgroup meetings; send meeting reminders, format agendas, minutes and handouts. Manage the team SharePoint site. Follow up on meeting action items. </p><h4>Duties Continued</h4><p>Work closely with QI, Health Services, Reporting/Analytics, vendors, and the provider network on shared quality initiatives, data sharing and analyses. </p><p>Monitor/track enterprise wide quality intervention and analytical strategies that elevate quality of care and enhance satisfaction for LAC members.&nbsp;</p><p>Work closely with Core Team of Analytics to lead quality reporting and analytical strategies to enable accountable entities and stakeholders to drive quality ratings improvement for Consumer Assessment of Healthcare Providers and Systems (CAHPS) and / or Health Outcome Survey (HOS) and /or Healthcare Effectiveness Data and Information Set (HEDIS), Medication Adherence and Plan Operations and /or other domains of focus such as Pharmacy and /or Administrative / Regulatory or other QRS specific metrics.</p><p>Assist with identifying measures that need performance improvement, evaluate data, coordinate discussion/workgroup to develop strategy and work plan.&nbsp;&nbsp;</p><p>Research and implement best practices to improve population health, quality of life and evaluate impact.&nbsp;&nbsp;</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><h4>Perform other duties as assigned.</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Health or Related Field<h4>Experience</h4><p>Required:</p><p>At least 5 years of experience in a health plan specializing in healthcare quality, informatics, QI initiatives and analytics. </p><p>Experience in implementing initiatives to improve quality ratings and managing projects and programs end to end.</p><p>Preferred: </p><p>Experience in a health plan specializing in Consumer Assessment of Healthcare Providers and Systems (CAHPS) and / or Health Outcome Survey (HOS) and /or Healthcare Effectiveness Data and Information Set (HEDIS), Medication Adherence and Plan Operations and /or other domains of focus such as Pharmacy and /or Administrative / Regulatory or other QRS specific metrics&nbsp; </p><p>Experience in implementing initiatives to improve quality ratings and managing projects and programs end to end for the above-specified metric sets. </p><h4>Skills</h4><p>Required:</p><p>Thorough knowledge on health plan quality ratings including Medicare Stars and / or Marketplace Exchange Quality Rating Systems (QRS).</p><p>Demonstrated analysis skills.</p><p>Must possess aptitude for accuracy and attention to details.</p><p>Proficient in Microsoft Office tools.</p><p>Ability to present data and analysis in a meaningful way, tailoring the message with audience in mind.</p><p>Excellent verbal, written and presentation skills.</p><p>Demonstrated critical thinking, problem-solving and process improvement skills.</p><p>Independent judgment and action skills to facilitate change as needed.</p><p>Knowledge of managed care industry standard performance assessment methods.</p><p>Able to work in a team environment, with good communication skills, supportive attitude and the ability to provide mentorship when appropriate.</p><p>Must demonstrate ability to work collaboratively and seek solutions proactively applying critical thinking skills in evaluating priorities and solutions.</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>                    Pharmacy, Medicare, Medicaid, Medical Research, Clinical Research, Healthcare                                                    </p>

Clinical Quality Program Manager III

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

65 L.A. Care Health Plan Jobs