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<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>

L.A. Care Health Plan

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>

Community Resource Center Specialist 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 Help Desk Technician II provides workstation phone, off site and onsite support for users, vendors and/or clients, resolving computer issues and help desk-related requests. This position plans, analyzes, configures, and installs new personal computer systems, determining user specifications for hardware and software upgrades; maintains and repairs existing computers; and deals with most issues that are simple or routine, escalating more complex or involved issues to Level II staff. This position composes documentation and communication regarding help desk/telephone support operations, and focuses on customer relations, achieving user comfort level on computer applications and equipment. This position may be required to travel on an as needed basis in order to fulfill user support responsibilities.</p><h4>Duties</h4><p><strong>Help Desk Coordination:</strong> Track all help desk issues and ensure that all are assigned to a staff member, are completed, and that users are kept informed of the status of their requests. (30%)</p><p><strong>User Support:</strong> Provide 1st-tier user support for all simple or routine user issues. Help users resolve system problems, utilize standard software, and maintain standard hardware. The Help Desk Technician may be required to travel on an as needed basis in order to fulfill user support responsibilities. (30%)</p><p><strong>Account Creation:</strong> Create standard accounts for new users for workstation login or email. Assign users to established groups and assign standard file permissions on appropriate servers. (15%)</p><p><strong>Maintain Supplies:</strong> Responsible for maintaining computer-related supplies (toner cartridges, floppy disks, backup tapes, etc.). Keep track of use, research prices, submit expenditure requests when needed, and ensure that consumables don't run out. Ensure that new hardware is accurately entered into the FAS accounting system. Workstation Roll out/Patching: Provide manpower for workstation rollouts and applying patches to workstations. (15%)</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 Degree<h4>Experience</h4><p>Required:</p><p>At least 2 years of experience in configuring &amp; administering networked computer systems in a Windows environment.</p><p>Strong experience with TCP/IP, Microsoft Outlook Email, Laptops and PDAs such as blackberry.</p><p>Experience in providing support to telecommute &amp; mobile laptop users required. </p><h4>Skills</h4><p>Required:</p><p>Familiar in configuring remote LAN access for VPN. </p><p>Excellent team work ethic.</p><p>Excellent communication and customer service skills. </p><p>Working knowledge of the Microsoft Office Suite, Windows XP/7 and Active Directory.</p><p>Preferred:<br>Strong PC and desktop application knowledge.</p><p>Strong computer troubleshooting and problem solving skills.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Computing Technology Industry Association (CompTIA) A+ CertificationHelp Desk Institute (HDI) Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Moderate<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                </p>

Help Desk Technician II

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

Senior Director, Technology Solutions and Support Services

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

Manager, Community Resource Centers

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

65 L.A. Care Health Plan Jobs