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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>The Report Writer III is responsible for data consolidation, data analysis and management reporting. This position utilizes software to generate metrics and develops actionable recommendations. This position provides support to teams and/or management by collecting and analyzing data and reporting results. Collaborates with various function teams to achieve business results. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Responsible for database administration, data consolidation, data analysis and management reporting. Collaborates with end users to gather report requirements and ensure proper testing and validation. Provides support to end users on standardized and ad hoc reports. Acts as liaison with the I.T. department.</p><p>Performs technical and analytical work to support the functional and reporting requirements of the department. Analyzes tables in the information system to establish knowledge of data for accurate retrieval and use in report writing. Plays an active role in identifying requirements and workflow associated with the systems upgrades and implementations. </p><p>Presents report data in a way that is most meaningful and readily accessible to staff and faculty using a combination of system reports. Demonstrates outstanding communication skills to translate reporting requests in order to accurately meet the actual information and deadline needs of users. </p><p>Educates requestors as to appropriate and desirable parameters to ensure they get the information they need.</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 Computer Science or Business AdministrationIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:</p><p>At least 3 years of experience working with healthcare data in a reports development role, direct experience developing reports derived from an Access, SQL or Oracle database in a healthcare setting, working with healthcare data and be proficient in claims and/or encounter data.</p><p>Prior healthcare experience, working on the core system (QNXT), with at least 5 years’ experience performing system integration testing (SIT) and/or user acceptance testing (UAT). </p><p>Preferred:</p><p>At least 3 years of programming and data analysis experience in a healthcare setting with at least 5 years of experience working with Medi-Cal managed care and/or commercial healthcare data. </p><p>Prior experience working with Core membership systems implementations, with at least 5 years of experience managing system implementations and performing system integration testing (SIT) and user acceptance testing (UAT). </p><p>Prior experience working within a project management structure.</p><h4>Skills</h4><p>Required:<br>Must have solid understanding of report development methodologies and be able to assess appropriate methodologies for the work assigned to the unit.&nbsp;</p><p>Must have excellent communication skills, strong analytical and coaching/mentoring skills, team building skills and the ability to work effectively with diverse team members.&nbsp;</p><p>Must have the ability to perform extensive root cause analysis of problem areas and recommend alternative solutions.&nbsp;</p><p>Must be able to work in an environment where critical time constraints exist.</p><p>Preferred:&nbsp;<br>Knowledge of 837 and NCPDP file formats.</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>Additional Essential Duties and Responsibilities to Dept. Specific (Enrollment Services):<br>Responsible for database administration, data consolidation, data analysis, management reporting and operational reporting specific but not limited for Customer Solutions Center, which includes Enrollment Services, Even MORE, Call Center and Appeals &amp; Grievances. Collaborates with end users to gather report requirements and ensure proper testing and validation. Provides support to end users on standardized and ad hoc reports. Acts as liaison with the I.T. department.&nbsp;</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Call Center, Insurance, Customer Service                                                    </p>

L.A. Care Health Plan

Report Writer III

<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><br>The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines.</p><p>Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases, which are those with the severest acuities or care needs and requiring the highest clinical skills and judgement. &nbsp;Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner.&nbsp;</p><p>Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team. Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member information, document contacts, and track member progress.&nbsp;</p><h4>Duties</h4><p>Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs.</p><p>Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives; reviewing member claims histories and identifies intervention opportunities through the professional standards of practice; contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits; conducting comprehensive clinical assessments as indicated; developing a member centric plan of care. Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence).&nbsp; </p><p>Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies.</p><p>Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions.</p><h4>Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.</h4><h4>Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes.</h4><h4>Duties Continued</h4><h4>Meets and assesses members at L.A. Care Community Resource Centers, as needed.</h4><h4>Provides effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines.</h4><h4>Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate.</h4><h4>Encourages member and family empowerment through education and use of reliable resources.</h4><h4>Monitors and evaluates member progress: evaluates member response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assesses effectiveness of care plan’s goals and interventions on a regular basis.</h4><h4>Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member's clinical records to promote care coordination. </h4><h4>Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage.</h4><h4>Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training.</h4><h4>Performs other duties as assigned.</h4><h4>Education Required</h4>Associate's Degree in Nursing for Registered NursesMaster's Degree in Social Work for Licensed Clinical Social Workers<h4>Education Preferred</h4>Bachelor's Degree in Nursing for Registered Nurses<h4>Experience</h4><p><br><strong>Required:</strong><br>Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments. &nbsp;</p><p>Experience providing care management with complex/catastrophic conditions.</p><h4>Skills</h4><p><br>Required:<br>Current knowledge of clinical standards of care and disease processes.</p><p>Critical thinking skill.&nbsp;</p><p>Excellent customer service skills.</p><p>Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions.</p><p>Ability to triage immediate member health and safety risks.</p><p>Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping.</p><p>Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders. &nbsp;</p><p>Ability to use a personal computer, and knowledge of medical information systems.</p><p>Knowledge of and ability to comply with HIPAA compliance.</p><p>Ability to interview, assess and coordinate care. Ability to prioritize caseload.</p><p>Knowledge of community resources.</p><p>Knowledge of Medi-Cal and Medicare regulations.</p><p>Ability to work as a part of a diverse team and gain consensus and resolution of problems.</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>Registered Nurse (RN);current and unrestricted California License OR Licensed Clinical Social Worker; 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>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>                    Social Worker, Travel Nurse, Nursing, Registered Nurse, Behavioral Health, Service, Healthcare                                                    </p>

Care Management Specialist II (D-SNP)

<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 Customer Solution Center Workforce Management (WFM) Analyst I is primarily responsible for real-time management of the call center queues, schedule maintenance and the management of exceptions.</p><h4>Duties</h4><p><br>Real-time monitoring and management of call center queues; to include, but not limited to: monitors for agent adherence to scheduled activities; excessive state durations; collaborates with call center leads and supervisors to manage agent behaviors; Recommend real-time schedule changes and identify efficiency opportunities. Skilling agents to respond to real time queue conditions and performing start and end of day skilling activities as assigned. (40%)</p><p>Optimizes scheduled breaks and lunches as resource requirements change, determine need for extra hours and/or leave early, assess availability for offline functions and approve/deny as required. Reviews and responds to schedule change requests. Updates schedules with last minute changes. Assists with the creation of all schedule runs and schedule bids/changes. (25%)</p><p>Uses established guidelines, process exception requests as submitted by call center agents and supervisors within the assigned timelines. Processes exceptions to schedules to support training, coaching and meeting requests while ensuring that there is adequate coverage for the call center queues. Evaluates and suggest alternate avenues for supporting off phone activities where queue coverage is limited. (25%)</p><p>Perform 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 or Bachelor's Degree<h4>Experience</h4><p>Required:<br>At least 2 years of contact center experience including real time adherence.</p><p>Demonstrated experience finding multiple solutions to complex problems.</p><p>Experience and understanding of staffing, queues, and performance measurements.</p><p>Practical, hands-on experience with workforce management tools.</p><p>Preferred:&nbsp;<br>Experience in a multi-lingual, culturally-sensitive environment a plus.</p><p>Hands on experience with WFM Nice IEX Software. Contact center analytics and experience with queue monitoring software (Cisco)</p><h4>Skills</h4><p><br>Required:<br>Strong real time Analytical skills.</p><p>Ability to interpret WFM data to assist with determining staffing needs.</p><p>Intermediate computer proficiency, specifically Word and Excel.</p><p>Familiarity with call center terminology.</p><p>Superior customer service, communication, and problem–solving skills.&nbsp;</p><p>Proven ability to learn new tools, techniques and skills.</p><p>Proven ability to meet goals and deadlines.</p><p>Adept at managing multiple priorities and tasks in a fast-paced environment.</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, HR, Customer Service, Human Resources                                                    </p>

Customer Solution Center Workforce Management Analyst I

<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 Enhanced Care Management (ECM) Coordinator II provides a broad range of project and operational support to the Enhanced Care Management team.&nbsp; This position is responsible for coordinating and organizing Enhanced Care Management activities, by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up. This position supports the Enhanced Care Management administration team in the monitoring and oversight process by collecting information, communicating with members, providers, and internal departments, and tracking program and compliance reports.</p><h4>Duties</h4><p>The Enhanced Care Management Coordinator II supports all administrative and technical functions of the Enhanced Care Management authorization process including intake, logging, tracking and status follow-up. </p><p>Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely process referrals/authorizations in the UM system of record; Identify duplicate requests using claims to verify existing authorization. Independently identifying and appropriately returning any file that is a duplicate to one already processed in the system; Appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; Accurate Filing/Maintenance of confidential member information. Creating secure, complete, files. Interface with members, Enhanced Care Management personnel and other internal and external agencies; Ensure all referrals and authorizations comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete information i.e.: Population of Focus criteria, DX codes, CPT, HCPC codes. (40%)</p><p>Provide organizational and administrative support for Enhanced Care Management activities to help achieve desired goals.&nbsp; </p><p>Plan and coordinate meetings, events, and related project activities to facilitate the optimal performance of Enhanced Care Management. Handles scheduling and coordination for stakeholder and provider meetings; correspondence, and follow up reports; compiles meeting materials; and maintains updated information on Enhanced Care Management. Assist with disseminating program communications to internal and external stakeholders. Provides assistance to team members as needed to achieve department goals. (30%)</p><p>Supports the Enhanced Care Management program administration team in the monitoring and oversight process. </p><p>Maintains the regular reporting responsibilities for Enhanced Care Management; tracks report timeliness, and notifies team of delays. Assists with soliciting information from providers concerning member cases and program operations for grievance and appeal requests. Provides non-clinical support to the Enhanced Care Management Clinical Specialist to support the provider oversight and review process (20%)</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>Minimum of 1 year of coordinator experience in health care/health services, with at least 1 year of experience in Medi-Cal managed care and/or as a Medical Assistant.</p><h4>Skills</h4><p>Required:</p><p>Knowledge of medical terminology, ICD-10, HCPCS and CPT codes.</p><p>Strong verbal and written communication skills.</p><p>Proficiency with Microsoft Outlook, Word, Excel, PowerPoint.</p><p>Excellent organizational, interpersonal and time management skills.</p><p>Must be detail-oriented and a team player.</p><p>Persuasion Skills: Must be able to interface with members, medical personnel, and other internal and external agencies. This includes persuading others to comply with L. A. Care requirements, and providing information in a timely fashion.</p><p>Preferred:</p><p>Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese&nbsp;&nbsp; </p><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>                    Administrative Assistant, Claims, Medical Assistant, Administrative, Insurance, Healthcare                                                    </p>

Enhanced Care Management Coordinator 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 Clinical Data Analyst III supports Healthcare metrics, quality and process improvement activities by producing healthcare outcome measurements that are used for internal and external reporting, the tasks including data quality assurance, process programming, specification documentation and report developing.</p><p>The Clinical Data Analyst III designs, develops, and generates production and similar reports that may evolve into complex data analysis/data integration projects that this individual may be responsible for maintaining. The complex data analysis/integration projects are those, which may require periodic maintenance on a weekly, monthly, quarterly, biannual, or annual basis. This position works with Information Systems analysts when ongoing reports can be accurately transferred for production. </p><p>The Clinical Data Analyst III interprets and documents both written and verbal specifications. This position takes basic instructions or specifications and interviews with the client for complete details sufficient for writing data queries based for ad hoc and ongoing health care measures. This position must comprehend the relationships between the field elements in encounters and claims, membership, and provider databases. This position supports the functions related to quality improvement activities inclusive of quarterly reports that demonstrate health care outcomes in comparison to targets or national averages/percentiles published by recognized organizations such as National Committee for Quality Assurance (NCQA) and Center for Disease Control (CDC).&nbsp; Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Design, develop and maintain complex ongoing data projects. Design, develop, and generate ad hoc/production reports. Produce automatic, robust, timely and accurate results based on client specifications and as allowed by available resources. Produce complete documentation, QC reports and periodic results as scheduled. Identify and create work-around to generate valid results that meet the intent of the client's specifications.&nbsp;&nbsp; </p><p>Investigate and document organizational data flow and sources. Provide thorough documentation regarding current 1) data sources 2) data flow 3) current process and procedures to code, group, QC, link and seed the data. Develop automatic, robust and sharable Statistical Analysis System (SAS) or Structured Query Language (SQL) procedures and programs towards building a comprehensive clinical data repository.</p><p>Develop analytical programs, databases, routine procedures using SAS or SQL programming language. Create work tools that facilitate tasks by reducing paperwork and errors. Document assumptions, specification in a clear and sharable fashion.</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.&nbsp; Educate/Tutor clients/junior staff on maintenance/usage of database/solutions designed. Educate/Tutor junior staff on data/business knowledge and technical skills.</p><p>Communicate with stakeholders/clients/collaborators regarding project details and plans.</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>Master's Degree in Public Health or Related Field<h4>Experience</h4><p>Required:</p><p>At least 4 years of experience in designing, developing, generating and analyzing ad hoc/production reports in Healthcare/Managed Care setting.</p><p>Preferred:</p><p>Experience as a Clinical Data Analyst.</p><h4>Skills</h4><p>Required:</p><p>Must be able to apply and/or develop technical specifications for health care measures such as those used by National Committee for Quality Assurance (NCQA), HEDIS, Centers for Medicare and Medicaid Services (CMS), and State. </p><p>Must demonstrate advanced SQL and/or SAS skills in developing programs and procedures for analytics and quality assurance.</p><p>Must be able to present data in a format that is appropriate for analysis. This includes the ability to determine select the correct information for calculating basic rates, table configuration, and graphical presentations. </p><p>Must demonstrate an aptitude in learning and expanding abilities to use new applications with basic training.</p><p>Must be a self-starter and can multi-task and can take charge of assigned projects.</p><p>Must be able to make recommendations to the clients that demonstrate strengths and limitations of the organization's ability to meet the request.</p><p>Preferred:</p><p>Working knowledge of SAS Proc SQL, SAS Macro and database related SAS skills are highly preferred.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Statistical Analysis System (SAS) CertificationCertified Healthcare Data Analyst (CHDA)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Dept Specific:</p><p>Health Equity:&nbsp; </p><p>This position is located in the Health Equity department. It supports the short and long term operational and L.A. Care’s Health Equity and Disparities Mitigation initiatives. This role will develop, enhance, and health and social service needs (food, housing, care management) information and models that will have an impact on vulnerable communities. Through the application of data analytics and analyzing various data sources, this role will work to deliver valuable insights and recommendations to improve health equity and reduce health disparities.</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>                    Public Health, Clinic, Equity, Medicaid, Medicare, Healthcare, Finance                                                    </p>

Clinical Data Analyst III (Tableau, SQL)

<p>Salary Range:&nbsp;&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>PLEASE NOTE:&nbsp; This position will work&nbsp;Monday - Friday, 8 a.m. to 5 p.m. PST, with rotating holidays.</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.</p><h4>Job Summary</h4><p><br>The Customer Solution Center Appeals and Grievances (A&amp;G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS )Medi-Cal/Medicare, or commercial insurance.&nbsp;</p><h4>Duties</h4><p>Conducts intake/triage and appropriate classification of Clinical A&amp;G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department.</p><p>Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements.&nbsp; Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours.</p><p>Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.</p><p>Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE).&nbsp; Process the case thru to effectuation and final case documentation in the A&amp;G system of record.</p><p>Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).</p><p>Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.</p><p>When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps.&nbsp; In instances where necessary, sends written notifications to appropriate parties. All interactions including verbal outreach and written communication will be documented in the A&amp;G system of record. </p><p>Participates inter-rater reliability training and assessments.</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:</p><p>At least 5 years of experience in Clinical Nursing and 2 years in Medicare/ Medicaid in a managed care/ health plan environment. </p><h4>Skills</h4><p><br>Required:</p><p>Excellent interpersonal and communication skills. </p><p>Computer literacy and adaptability to computer learning. </p><p>Time management and priority setting skills.</p><p>Must be organized and a team player </p><p>Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.</p><p>Good working knowledge of regulatory requirements/standards.</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, Medicare, Medicaid, Pharmacy, Healthcare                                                    </p>

Customer Solution Center Appeals and Grievances Nurse Specialist RN II

<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>

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>

65 L.A. Care Health Plan Jobs