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<p><b>Salary Range:&nbsp;</b>&nbsp;$47,840.00&nbsp;(Min.) -&nbsp;$57,062.00&nbsp;(Mid.) -&nbsp;$68,474.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</p><p>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</p><p>In addition, the position performs data entry and processing of referrals/authorizations in the system, &nbsp;authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</p><h4>Duties</h4><h4>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services 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; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure&nbsp; all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</h4><h4>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</h4><h4>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</h4><h4>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</h4><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><h4>Experience</h4><p><b>Required:</b></p><p>At least 6 months of health care experience.</p><p>Experience working in a cross functional work environment.</p><p><b>Preferred:</b></p><p>Experience in Medi-Cal managed care.</p><p>1 year of experience in UM/Prior Authorization.</p><h4>Skills</h4><p><b>Required:</b></p><p>Demonstrated proficiency in Medical Terminology required.</p><p>Strong verbal and written office communication skills.</p><p>Proficient with Microsoft Office Suite and Adobe PDF. and </p><p>Excellent organizational, interpersonal and time management skills. </p><p>Must be detail-oriented and an enthusiastic team player.</p><p><b>Preferred:</b></p><p>Knowledge of QNXT computer systems a plus.</p><p>Knowledge of the UM patient referral process.</p><p>Knowledge of member’s health plan eligibility.</p><p>Knowledge of member’s benefits coverage. </p><p>Knowledge of Health Plan regulations.</p><p>Knowledge of HMO/UM functions.</p><p>Knowledge of ICD-10/CPT coding. </p><p>Proficient utilizing electronic medical records and documentation programs.</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><b>Required:</b></p><p>Weekends and holidays hours may be required, as well as OT based on a business need.</p><p><b>Salary Range Disclaimer:</b> 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><b>L.A. Care offers&nbsp;a wide range of benefits including</b></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, Data Entry, Medical Coding, Claims, Healthcare, Administrative, Insurance                                                    </p>

L.A. Care Health Plan

Authorization Technician II

<p><b>Salary Range:&nbsp;</b>&nbsp;$67,186.00&nbsp;(Min.) -&nbsp;$87,342.00&nbsp;(Mid.) -&nbsp;$107,498.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p><br>The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is responsible for assisting the Appeal and Grievances Compliance, Training and QA Manager to develop a successful and cohesive unit with a high level of productivity and focus on implementing, executing, tracking, and assessing targeted and random audits for non-clinical grievance and appeal case documentation. Ensure A&amp;G Non-Clinical staff is following all Regulatory guidelines, internal P&amp;Ps, Desktop Procedures, in a consistent and accurate manner.</p><p>This position will focus on quality review of non-clinical grievance and appeals cases for all line of business (LOB) to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care’s membership. This position is responsible for monitoring Appeal and Grievances Specialists, Lead Intake, and Senior Appeal and Grievances Specialists, performance against key performance indicators and recognizes trends that require individual or group retraining. The position conducts/reviews audits and analyzes the data and documentation and provides their input to management for review. In addition, is responsible for review and approval of all member letters prior to issuance.</p><p>This position facilitates recommendations for the development, review, and revision, as appropriate, of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational and departmental guidelines. Generates results of findings, enhances and analyzes various standard reports related to, but not limited to: quality and accuracy of case documentation. This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as needed to increase staff knowledge of L.A. Care, regulations, and departmental requirements. Compiles and presents quality report cards to measure quality enhancements and disseminates to appropriate parties as needed. This position will keep the QA Manager aware of trends, deficiencies and any potential issues that arise for review and evaluation by the Management Team.</p><h4>Duties</h4><p>Focus on quality review of grievance and appeals cases for all LOB to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care’s membership. Complete and accurate cases logged into the system. Thorough documentation of case investigation and resolution. Ensure that all appropriate correspondence is used for each LOB. Assists in document preparation for regulatory and internal audits.&nbsp;</p><p>Execute targeted and random audits to ensure that all regulatory guidelines, departmental policies, procedures and standards are being met, as well as the organization’s mission. Identify and report deviations in performance in advance and recommend process changes to redirect performance to acceptable levels.</p><p>Track and trend QA reviews, analyze results from scorecards and recommend quality improvements for the Appeal and Grievances Department.&nbsp;</p><p>Consistently participate in quality initiatives and special project task forces as deemed necessary.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree<h4>Experience</h4><p><br><b>Required:</b><br>At least 4 years of experience in auditing Appeals &amp; Grievances in a healthcare environment required.</p><h4>Skills</h4><p><br><b>Required:</b><br>Excellent verbal/written communication skills.</p><p>Advanced computer proficiency, Word, Excel; and Access.</p><p>Strong analytical and team building skills.&nbsp;</p><p>Ability to work effectively with diverse team members.&nbsp;</p><p>Ability to troubleshoot problem areas, formulate recommendations to improve quality and service delivery, and develop effective system and process improvements.</p><p>Ability to multi-task and streamline day-to-day operations.</p><p>Strong interpersonal and organization skills and is expected to work independently within the department's established guidelines, policies and procedures.&nbsp;</p><p><b>Preferred:</b><br>Health Plan auditing skills.</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>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><b>Salary Range Disclaimer:</b> 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><b>L.A. Care offers&nbsp;a wide range of benefits including</b></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>                    Audit, Finance                                                    </p>

Customer Solution Center Appeals and Grievances Quality Auditing Specialist II

<p>Come care with us at West Coast University! As a Nursing Faculty member for a certified Great Place to Work, you will guide nursing students to do more than change their own lives – you will help change the lives of every patient they treat throughout their career in healthcare.&nbsp; At West Coast University you will have the opportunity to share your success story with the next generation of nurses as a key member of our student-centered, innovative community!</p><p><strong>You will make an impact by:&nbsp;&nbsp;</strong></p><ul><li>Serving as a mentor, role model and facilitator who provides guidance and academic support for students.&nbsp;&nbsp;</li><li>Demonstrating enthusiasm for teaching, the teaching/learning process and for individual students.&nbsp;</li><li>Applying your skills and experience to your assigned teaching schedule.&nbsp;</li><li>Participating in and contributing to assessment activities of courses/curriculum and programs via a continuous improvement plan set forth by the University.&nbsp;</li><li>Regularly contributing to improvement of class materials and syllabi within prescribed shared governance culture.&nbsp;Utilizing a variety of teaching methodologies to instruct students, always with intent to facilitate observable evidence of student fulfillment of prescribed learning outcomes.&nbsp;</li><li>Maintaining scholarly activities.&nbsp;</li><li>Participating in professional growth and service in accordance with university policies.&nbsp;</li><li>Advancing our commitment and focus on the students we serve, and their success as healthcare professionals.&nbsp;</li><li>Fully leveraging our innovative technologies and resources, such as our Simulation and Innovation Labs.</li><li>*If working with students in a Clinical setting you will:<ul><li>Assume complete responsibility for students in clinical facilities.</li><li>Clarify clinical expectations with students.</li><li>Clarify student placement and expectations with clinical facility staff.</li><li>Utilize care planning time to direct students to available resources needed for clinical preparation.</li><li>Assess student knowledge and skill level to ensure safety and optimal care for patients.</li><li>Utilize pre- and post- conference to allow students an opportunity to share learned experiences, ensuring clarity of the correlation between weekly theory content with clinical objectives and experiences.</li><li>Provide feedback of clinical performance immediately after observation of event and of overall performance at midterm and end of semester.&nbsp;</li></ul></li></ul><p><strong>Your Experience Includes:&nbsp;&nbsp;</strong></p><ul><li>Working knowledge of Microsoft Office Suite Products, especially Outlook, Word, PowerPoint and other MS office products as needed.&nbsp;</li><li>Experience with online learning management systems to further engage the student learning process.&nbsp;</li><li>Compliance with state, federal and local laws/regulations relating to programs, governmental compliance, and other regulatory standards such as state Board of Nursing.</li><li>Clinical RN – Must have at least two (2) years’ experience as a registered nurse within the last five (5) years providing direct patient care and at least one year’s experience in the field they teach in.</li></ul><p><strong>Education:</strong></p><ul><li>Bachelor’s degree in specialty field required.</li><li>Professional nurse licensure required.&nbsp;</li></ul><p><strong>Do you want a career that allows you to make a difference in other people’s lives? Discover what it means to truly believe in the work that you do at West Coast University.</strong></p><p>At West Coast University, we have the privilege of educating students seeking careers in healthcare and guide them through their transformational journey from student to caregiver. Our associates are united behind that purpose and share a deep commitment to our values of teamwork, collegiality, transparency, and a student-centric approach to all we do. This focus creates an aligned, nimble, and consensus-driven culture that is solution-oriented and supports our associates’ professional growth.</p><p><em>West Coast University is proud to be an equal opportunity employer. We embrace diversity and are dedicated to creating an inclusive environment for all associates.</em></p>

West Coast University

Adjunct Medical Surgical Clinical Instructor( Nights)

<p><strong>Pay Range:</strong>&nbsp;$17.00&nbsp;-$28.00&nbsp;</p><p><strong>Join the Clean Energy Revolution&nbsp;</strong></p><p>Become a summer intern at Southern California Edison (SCE) and build a better tomorrow. In this 12-week internship, you’ll gain hands on experience with meaningful work while developing essential skills and building your professional network. We’re big believers that diversity leads to innovation, creativity, and collaboration. As a summer intern, your work will help power our planet, reduce carbon emissions and create cleaner air for everyone. Are you ready to take on the challenge to help us build the future?&nbsp;</p><p><strong>Responsibilities&nbsp;</strong></p><ul><li>Come prepared to work on real world challenges within the utility/energy sector&nbsp;</li></ul><ul><li>You’ll be paired with a mentor and work collaboratively to apply your knowledge, grow your skills and make an impact&nbsp;</li></ul><ul><li>Build your professional network through various intern events&nbsp;</li></ul><ul><li>Work with cross functional teams on projects&nbsp;</li></ul><ul><li>Ongoing support to grow personally and professionally&nbsp;</li></ul><ul><li>Present in annual Intern Expo to showcase assigned internship project&nbsp;</li></ul><ul><li>Gain hands-on experience with industry-relevant software and tools aligned within your field of study&nbsp;</li></ul><ul><li>Effective and open communication&nbsp;</li></ul><p><strong>Minimum Qualifications&nbsp;</strong></p><ul><li>Currently pursuing a Bachelor’s Degree or higher (INSERT MAJOR) at an accredited institution with a graduation date of December 2026 or later&nbsp;</li></ul><ul><li>2.8 GPA or higher&nbsp;</li></ul><h4><b>Responsibilities</b></h4><h4><b>Minimum Qualifications</b></h4><p><strong>Additional Information</strong></p><ul><li>This position’s work mode is on-site. The employee will report to an SCE facility or in the field location. Further details of this work mode will be discussed at the interview stage. The work mode can be changed based on business needs.&nbsp;</li></ul><ul><li>This position’s work mode is hybrid. The employee will report to an SCE facility for a set number of days with the option to work remotely on the remaining days.  Unless otherwise noted, employees are required to reside in the state of California.  Further details of this work mode will be discussed at the interview stage. The work mode can be changed based on business needs.&nbsp;</li></ul><ul><li>The position’s work mode is remote. Employee is able to work primarily at home or remote however, the employee may be expected to come to an SCE facility on occasion. Unless otherwise noted, employees are required to reside in the state of California. Hiring organizations can add further requirements related to specific jobs. Further details of this work mode will be discussed at the interview stage. The work mode can be changed based on business needs&nbsp;</li></ul><ul><li>The internship has a start date of May/June 2026 and end date of August/September 2026.&nbsp;</li></ul><ul><li>Official transcripts will be verified during the on-boarding process.&nbsp;</li></ul><ul><li>We require you to be legally authorized to work for any employer in the United States without visa sponsorship.&nbsp;</li></ul><ul><li>Visit our Candidate Resource page to get meaningful information related to resources, testing information, the hiring process, and more! · Visit our Candidate Resource page to get meaningful information related to benefits, perks, resources, testing information, hiring process, and more!&nbsp;</li></ul><ul><li>Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.&nbsp;</li></ul><p><strong>Relocation&nbsp;&nbsp;</strong></p><ul><li>Relocation or housing does not apply to this position.&nbsp;</li></ul><p><strong>About Southern California Edison&nbsp;</strong></p><p>The people at SCE don't just keep the lights on. Our mission is so much bigger. We’re fueling the kind of innovation that’s changing an entire industry, and quite possibly the planet. Join us and create a future with cleaner energy, while providing our customers with the safety and reliability they demand. At SCE, you’ll have a chance to grow personally and professionally, making a real impact in Southern California and around the world.&nbsp;</p><p>At SCE, we celebrate our differences. We are a proud Equal Opportunity Employer and will not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected status.&nbsp;</p><p>We are committed to ensuring that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodations at (833) 343-0727.&nbsp;</p>

530 Jobs in Arcadia, CA, USA