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<p><b>Salary Range:&nbsp;</b>&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 Manager, Service Validation Unit (SVU) manages and leads L.A. Care’s pre-payment service validation function designed to strengthen program integrity and prevent improper payments before claims are released. This position oversees processes that independently verify the accuracy, authenticity, and appropriateness of billed services by conducting structured outreach to members, referring/rendering providers, and other stakeholders.</p><p>The Manager ensures timely, accurate, and thorough completion of validation activities prior to adjudication, including verification of dates of service, service receipt, provider involvement, referral accuracy, and benefit/authorization alignment. This position ensures that SVU decisions support correct payment, reduce waste and rework, and strengthen the end-to-end claims ecosystem.</p><p>The Manager partners closely with cross-functional key stakeholders to ensure findings lead to upstream improvements and preventive control enhancements. This position oversees a team responsible for outreach, documentation, triage, and evidence collection.</p><p>The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendations on the department's strategic planning and/or long-term decision-making.</p><h4>Duties</h4><h4>Ensures that L.A. Care maintains a disciplined, consistent, and defensible pre-payment validation process supporting payment accuracy, program integrity, and member protection. Builds a strong preventive control environment by validating services before payment, ensuring SVU determinations are timely, reliable, well-documented, and integrated with upstream operational improvements.</h4><p>Leads daily SVU operations, including member and provider contact workflows, service verification, documentation review, and adjudication hold/release decisions. Ensures SVU activities occur within established timeframes to avoid payment delays while maintaining thorough and accurate validation. Applies consistent criteria to verify whether billed services were received, ordered, properly represented, and appropriately billed. Ensures SVU staff follow standardized scripts, documentation requirements, and outreach protocols.</p><p>Oversees timely and professional outreach to members to validate service receipt, provider, date of service, and any concerns or discrepancies. Ensures referring and rendering providers are contacted for clarity on orders, referrals, documentation, or medical necessity questions when appropriate. Ensures escalations are addressed when discrepancies or concerning patterns are identified. Ensures high-quality communication that supports member trust, minimizes abrasion, and protects Protected Health Information (PHI).</p><p>Works closely with cross-functional key stakeholders to identify trends that may signal fraud, waste, abuse, overbilling, or systemic issues. Refers suspicious patterns to SIU or Payment Integrity with complete, documented findings. Ensures the SVU functions as a preventive control aligned with enterprise accuracy and program integrity goals. Supports the shift toward proactive cost avoidance and upstream error prevention.</p><p>Ensures validated claims are released for adjudication promptly and that holds are applied only when necessary. Partners with Claims Administration to establish clear criteria for what types of claims or services require SVU review. Collaborates with Configuration and Provider Network to ensure benefit and contract rules are accurately reflected in SVU criteria. Provides recommendations to improve system edits, benefits configuration, authorization processes, and provider education.</p><p>Ensures SVU findings are documented clearly, consistently, and in compliance with regulatory standards. Oversees development of dashboards tracking SVU volume, disposition categories, turnaround times, verification outcomes, and trend indicators. Identifies emerging issues and communicates upstream risks involving specific providers, services, benefit types, or claim categories. Prepares executive summaries and supports regulatory or audit inquiries related to SVU processes.</p><h4>Duties Continued</h4><h4>Continuously refines SVU criteria, outreach scripts, validation logic, and documentation workflows. Partners with operational teams to incorporate new benefit rules, system changes, or regulatory updates into SVU processes. Improves handoffs between cross -functional key stakeholders.</h4><h4>Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Manages, leads, trains, coaches, and develops staff to ensure accuracy, professionalism, and strong investigative skills. Ensures team members are trained in verification protocols, communication standards, confidentiality requirements, and documentation practices.</h4><h4>Creates a culture that values member respect, accuracy, proactive issue identification, and cross-functional collaboration. Drives accountability through transparent goals, consistent feedback, and measurable performance metrics. Supports a positive, collaborative culture that values accuracy, teamwork, transparency, and customer-focused operational excellence.</h4><h4>Ensures ongoing team development, cross-training, and readiness for regulatory, operational, or system-driven changes. Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</h4><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.</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 in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience in healthcare operations.</p><p>At least 3 years of leading, supervising/managing staff.</p><p><strong>Equivalency:</strong>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p>Experience conducting provider or member outreach, case review, or data validation.</p><p>Deep experience with data validation and operational Quality Assurance (QA) techniques</p><p><strong>Preferred:</strong></p><p>Experience interpreting managed care benefits, authorization processes, coding, and provider contract terms.</p><p>Experience in Medicaid, Medicare, and/or Commercial lines of business.</p><p>Experience with data validation or operational QA techniques.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong investigative, analytical, and communication skills.</p><p>Ability to manage sensitive member/provider interactions with professionalism.</p><p>Strong documentation and audit-readiness skills.</p><p>Ability to manage time-sensitive workflows while maintaining accuracy.</p><p>Proficiency in Microsoft Office and claims data tools.</p><p>Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Strong verbal, written communication and presentation skills.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><p><strong>Preferred:</strong></p><p>Knowledge of FWA indicators, SIU protocols, and program integrity practices.</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><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>                    Claims, Service Manager, Medicaid, Medicare, Insurance, Customer Service, Healthcare                                                    </p>

L.A. Care Health Plan

Manager, Service Validation Unit

<p><b>Salary Range:&nbsp;</b>&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 Manager, Claims Research and Remediation manages L.A. Care’s specialized “Tiger Team” responsible for investigating, reconstructing, quantifying, and remediating the most complex and high-risk claims issues across the enterprise. This includes deep-dive root cause analysis (RCA), litigation-related claims support, systemic defect reconstruction, mass adjustment planning, execution, and large-scale remediation efforts required to mitigate legal, regulatory, or financial exposure.&nbsp;</p><p>The Manager serves as a trusted operational partner to cross-functional key stakeholders by conducting high-precision analyses, validating claim impacts across multiple time periods, creating audit-ready documentation, and designing remediation strategies that reduce risk and recommends quality assurance protocols to ensure accuracy across the claims ecosystem.</p><p>The Manager manages and leads staff who research and remediate complex providers, contracts, benefit structures, retroactive policy changes, system defects, and multi-year claim reviews. The position ensures deep analytical rigor, data integrity, quality control, and cross-functional coordination in all remediation work.</p><p>The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendation on the department's strategic planning and/or long-term decision-making.</p><h4>Duties</h4><p>Drives L.A. Care’s most critical investigative and corrective work. &nbsp;Deals with the highest regulatory, financial, or legal exposure. Ensures that investigations are comprehensive, evidence-based, and defensible, and that remediation actions are accurate, auditable, and sustainable. Leveraging analytics, structured project leadership, and strong cross-functional collaboration, protects the organization while strengthening upstream processes and long-term operational reliability.</p><p>Leads the investigation of complex issues involving benefit configuration errors, contract misinterpretation, pricing defects, authorization discrepancies, coding anomalies, or systemic system defects. Reconstructs claims outcomes across multiple adjudication cycles, benefit periods, and contract iterations to determine root cause and impact. Conducts multi-layered RCA involving claims rules, configuration tables, provider contracts, Electronic Data Interchange (EDI) inputs, pricing logic, benefit grids, Utilization Management (UM) decisions, and historical system changes. Develops complete audit trails documenting “what happened,” “why it happened,” and “how to prevent recurrence.”</p><p>Partners with Legal to support litigation research, discovery preparation, and exposure modeling. Conducts claims sampling, case reconstruction, data pulls, validation, and preparation of evidentiary claim packages. Provides operational insights and documentation required for regulators, external auditors, and legal proceedings. Works with Compliance to design corrective action plans and support enterprise readiness during regulatory reviews, inquiries, or settlements.</p><p>Partners with Claims Administration and Quality Assurance (QA) in the development of end-to-end remediation plans, including identification, retrieval, correction, reprocessing, and reconciliation of affected claims. Oversees multi-layered remediation for retroactive benefit changes, contract corrections, reimbursement updates, or operational/system defects. Ensures remediation execution is compliant, accurate, documented, and coordinated with cross-functional key stakeholders. Recommends QA/validation protocols before, during, and after remediation cycles.</p><h4>Duties Continued</h4><p>Develops models to quantify regulatory, legal, or financial exposure across multiple scenarios. Validates datasets received from other business units and ensures completeness, accuracy, and audit-readiness. Performs scenario testing to predict downstream implications of proposed changes, settlements, or corrective actions. Partners with Finance on financial projections and reserve-setting guidance.</p><p>Works closely with cross-functional key stakeholders to validate findings and ensure remediation is accurate and aligned with operational rules. Identifies upstream gaps uncovered during investigations and partners with business owners to implement preventive controls. Provides recommendations for system enhancements, procedural changes, or policy updates to reduce recurrence of similar issues.</p><p>Creates executive-level reports summarizing findings, root causes, risks, and recommended actions. Produces audit-ready documentation for regulators, legal stakeholders, Compliance, and leadership. Maintains strict confidentiality, secure data handling protocols, and precise audit trails.</p><p>Manage staff, including, but not limited to: monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Assigns work, monitors progress, ensures quality, and maintains strong project management discipline. Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.</p><p>Performs 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 in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience working in claims research, auditing, payment integrity, provider disputes, adjustments, or complex claims operational functions.</p><p>At least 3 years of leading, supervising /managing staff.<br><br></p><p><strong>Equivalency:</strong>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Deep experience interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Demonstrated experience with high complexity claims review and RCA.</p><p>Experience interacting with Legal, Compliance, or regulators.</p><p>Strong experience with claims system logic, configuration dependencies, provider contracts, and benefit structures.</p><p><strong>Preferred: </strong></p><p>Experience supporting litigation, corrective action plans, or legal inquiry responses.</p><p>Experience with multi-system data validation or complex SQL/data analysis.</p><p>Coding experience or equivalent knowledge.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Expert-level analytical and investigatory skills. Ability to analyze complex datasets and reconcile conflicting data sources.&nbsp;Exceptional presentation skills, written and verbal communication skills, including executive communication skills with the ability to produce audit-ready documentation.&nbsp;Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.&nbsp;Strong understanding of pricing methodologies, coding rules, benefit logic, and contract interpretation.&nbsp;Deep knowledge of relevant regulatory requirements (Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)).&nbsp;High proficiency with Excel, SQL, Access, or claims-data tools.&nbsp;Ability to lead cross-functional, high-pressure, confidential initiatives with minimal oversight.&nbsp;Demonstrated ability to make informed decisions.&nbsp;Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.&nbsp;Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.&nbsp;Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.&nbsp;Must have a deep understanding of financial principles. Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation. Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges. Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><p><strong>Preferred:</strong></p><p>Ability to review claims in 360-degree approach.</p><p>Ability to present findings to various levels of management, and including stakeholders, across all organization.</p><p>Coding certifications (CPC, CCS) or equivalent knowledge.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC) or other equivalent Coding Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><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>                    Medical Coding, Claims, Medicare, Medicaid, Healthcare, Insurance                                                    </p>

Manager, Claims Research and Remediation

<p><b>Salary Range:&nbsp;</b>&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 Engagement and Experience Compliance and Quality Auditor II is responsible for evaluating the accuracy, compliance, and quality of customer interactions within L.A. Care’s Customer Engagement and Experience operations. This position conducts targeted audits of member interactions, documentation, and service workflows to ensure adherence to federal/state regulations, Centers for Medicare and Medicaid Services (CMS) and Medicaid requirements, National Committee for Quality Assurance (NCQA) standards, internal policies, and customer service best practices. The Auditor identifies risks, trends, training needs, and opportunities for improvement while supporting regulatory readiness and service excellence initiatives.</p><h4>Duties</h4><p>Evaluates customer interactions across all channels (calls, chat, email, and correspondence) for accuracy, professionalism, empathy, and service quality. Verifies representatives provide correct benefit information, follow call scripts, and use approved language. Reviews documentation to ensure complete, timely, and accurate recording of member interactions. Audits customer interaction records to ensure adherence to CMS guidelines, state Medicaid rules, NCQA standards, Health Insurance Portability and Accountability Act (HIPAA), privacy regulations, and internal compliance policies. Identifies potential compliance risks such as benefit misinterpretations, incomplete disclosures, or policy deviations. Flags issues for corrective action and escalates high-risk findings per protocol. (50%)</p><p>Prepares detailed audit reports summarizing findings, trends, error types, and opportunities for improvement. Tracks performance results at the individual, team, and process level. Presents audit insights to leadership. (10%)</p><p>Participates in Root Cause Analysis (RCA) for recurring quality issues, compliance gaps, or service failures. Collaborates with internal teams to develop and implement corrective actions. Validates the effectiveness of remediation efforts through follow-up audits. (5%)</p><p>Provides feedback to key stakeholders regarding knowledge gaps, script deviations, or policy misunderstandings. Assists in creating or updating Quality Assurance (QA) scorecards, training materials, workflows, and Standard Operating Procedures (SOPs). Participates in calibration sessions to maintain scoring accuracy and consistency. (10%)</p><p>Assists with audit readiness for CMS, California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), NCQA, internal audits, and other external oversight bodies. Maintains documentation and evidence supporting compliance with regulatory audit requirements. Supports quality improvement initiatives tied to Consumer Assessment of Healthcare Providers and Systems (CAHPS), Medicare Stars, grievance reduction, call accuracy, and member experience targets. (10%)</p><p>Works closely with internal teams to support operational excellence. Serves as a key resource on contact center quality and compliance expectations. (5%)</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><strong>Required:</strong></p><p>At least 2 years of experience in health plan operations, contact center quality assurance, compliance auditing, or member services.</p><p>Experience in managed care customer service or contact center environments.</p><p><strong>Preferred:</strong></p><p>Experience with Medicaid/Medicare/Commercial requirements, CMS contact center standards, and NCQA regulations.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong knowledge of health plan benefits, customer service workflows, and contact center operations.</p><p>Familiarity with CMS call monitoring guidelines and regulatory requirements.</p><p>Excellent attention to detail and ability to identify compliance and quality issues.</p><p>Strong critical thinking, analytical, and documentation skills.</p><p>Excellent communication skills, with ability to deliver constructive feedback.</p><p>Proficient in QA platforms, CRM systems, and call monitoring tools.</p><p>Ability to maintain confidentiality and adhere to HIPAA/privacy standards.</p><p>Proficient in MS Office.</p><p>Ability to coach and train employees.</p><p><strong>Preferred:</strong></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.</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><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>                    Medicaid, Medicare, Audit, Healthcare, Finance                                                    </p>

Customer Engagement and Experience Compliance and Quality Auditor II

<p><b>Salary Range:&nbsp;</b>&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 of Customer Engagement and Experience Quality Assurance (QA) is responsible for leading quality oversight, service excellence, and member experience improvement activities within the health plan’s customer experience operations. This position ensures that customer service cross functional teams deliver accurate, high-quality, culturally competent support to members.</p><p>The Manager oversees QA reviews, conducts experience analytics, guides service improvement initiatives, and partners with operational leaders to strengthen performance tied to Consumer Assessment of Healthcare Providers and Systems (CAHPS), STARS, Centers for Medicare and Medicaid Services (CMS)/State requirements, and organizational service standards.</p><p>The Manager is also responsible for effectively representing the department and the organization for various audits, initiatives, etc. and facilitating and/or providing technical expertise and support for various cross-functional meetings, task forces, and committees.</p><p>The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendation on the department's strategic planning and/or long-term decision-making.</p><h4>Duties</h4><p>Leads the development, execution, and continuous enhancement of the customer experience QA program. Creates and maintains QA scorecards, evaluation criteria, scripts, and standards aligned with health plan policies and regulatory requirements. Conducts regular calibrations with supervisors and operational leadership to ensure scoring consistency and fairness. Evaluates all forms of member interactions for accuracy, empathy, compliance, and resolution quality.</p><p>Monitors and interprets trends in member experience metrics, including CAHPS, satisfaction surveys, complaints, and grievance themes. Identifies root causes of negative member experiences and recommends targeted solutions. Leads initiatives that improve first call resolution, member education, clarity of communication, and service recovery effectiveness. Supports culturally sensitive and health-literate communication practices across customer experience service teams.</p><p>Works closely with customer experience leadership to provide recommendations for process improvements, workflow optimization, and service protocols. Tracks performance outcomes and collaborates on coaching plans for teams and individuals. Provides timely feedback to supervisors and frontline staff to reinforce excellence and correct deficiencies.</p><p>Partners with Training/Learning and Development to design onboarding and ongoing training aligned with QA findings. Ensures training content reflects service expectations, regulatory updates, and quality standards. Facilitates QA refresher sessions, coaching workshops, and service excellence training as needed.</p><p>Prepares QA documentation and evidence for regulatory reviews, internal audits, and accreditation surveys. Supports the development and monitoring of corrective action plans when compliance issues arise.</p><p>Develops and maintains dashboards and reports that track QA outcomes, experience trends, and service performance. Presents insights to leadership, identifying risks, opportunities, and actionable recommendations. Monitors Key Performance Indicators (KPIs) such as call accuracy, empathy quality, service level impact, error rates, and first call resolution.</p><p>Partners cross-functionally to align on experience strategy. Participate in cross-functional initiatives to improve end-to-end customer experience and streamline the member journey. Serves as a subject matter expert on service quality, customer engagement, and experience-driven best practices.</p><p>&nbsp;Conducts development planning. Fosters a culture of accountability, team collaboration, and service excellence.</p><p>Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</p><p>Responsible for reporting, budgeting, and policy implementation.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><strong>Required:</strong></p><p>At least 4 years of experience in customer service operations within a health plan or healthcare environment.</p><p>At least 3 years of experience in leading, supervising and/or managing staff.</p><p><strong>Equivalency:</strong>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>At least 3 years of experience in quality assurance, customer experience, or service excellence.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p><strong>Preferred:</strong></p><p>Prior exposure to CAHPS improvement, health plan call center metrics, and service audits highly preferred.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of health plan operations, benefits, and regulatory standards.</p><p>Excellent analytical, quality auditing, and reporting skills.</p><p>Ability to translate data into insights and actionable performance improvements.</p><p>Exceptional communication, coaching, and facilitation skills.</p><p>Strong leadership skills and ability to motivate and support teams.</p><p>Knowledge of service quality frameworks, root-cause analysis, and continuous improvement methodologies (e.g., Lean/Six Sigma) is a plus.</p><p>High attention to detail and organizational skills.</p><p>Proficiency in MS suite.</p><p>Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles. Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Strong verbal, written communication and presentation skills.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</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><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>                    Call Center Manager, Call Center Supervisor, Call Center, Medicaid, Medicare, Customer Service, Healthcare                                                    </p>

Manager, Customer Engagement and Experience Quality Assurance

<p><b>Salary Range:&nbsp;</b>&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 Manager, Claims Quality Assurance (QA) is responsible for managing and leading the operational quality program focused on preventative and predictive orientation that evaluates and strengthens accuracy across the entire claims lifecycle from receipt and intake through adjudication, adjustments, disputes, and post-payment verification. This position ensures L.A. Care’s Core Administrative Operations maintain high processing accuracy, strong control points, and consistent application of benefits, provider contracts, coding standards, and regulatory requirements.</p><p>The Manager oversees operational QA testing, examiner-level audit programs, quality scoring, root-cause identification, and corrective action validation. This position also supports regulatory readiness through mock audit participation, audit universe/sample creation, and quality documentation preparation. Works in partnership with leadership. This position manages staff and partners closely with cross functional key stake holders to drive upstream improvements while aiming to remove rework.</p><p>The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendations on the department's strategic planning and/or long-term decision-making.</p><h4>Duties</h4><h4>Builds a disciplined quality review framework that increases first-pass accuracy, reduces preventable defects, strengthens upstream controls, and ensures consistent application of rules across the claims lifecycle. Through rigorous audit practices, validation of corrective actions, and structured feedback loops, this role enhances operational predictability and ensures readiness for regulatory audits.</h4><h4>Oversees audits across the entire operational claims lifecycle including claim intake, data entry, adjudication, pricing, coding accuracy, benefit interpretation, provider contract application, and documentation. Monitors and validates adjustment processing, provider disputes resolutions, and post-payment quality outcomes tied to Payment Integrity remediation. Ensures quality reviews measure accuracy, consistency, and compliance with policies, benefit structures, provider contracts, coding standards, pricing methodologies, and regulatory expectations. Ensures QA findings are accurate, evidence-based, and actionable for operational leaders.</h4><h4>Designs and oversees the claims QA audit methodology, including sampling standards, audit frequency, scoring tools, examiner scorecards, and quality thresholds. Co-leads claims components of mock audits for regulatory agencies, and related review bodies. Prepares audit universes, conducts sample reviews, organizes evidence, and ensures accuracy of documentation for internal/external audits. Ensures QA processes meet expectations for regulatory audit readiness.</h4><h4>Conducts root-cause analysis on quality findings to identify systemic drivers behind defects or inconsistencies.</h4><h4>Works with cross functional key stakeholders to implement and validate corrective actions. Confirms that corrective actions address underlying issues and reduce recurrence. Tracks error trending to identify early signals of operational or regulatory risk.</h4><h4>Maintains claims QA guidelines, audit manuals, sampling methodologies, scoring rules, and documentation requirements. Develops quality dashboards, trend analyses, and quality scorecards for Core Administrative Operations leadership. Ensures quality results are communicated clearly, consistently, and with actionable recommendations. Monitors adherence to quality standards across examiners, analysts, and adjustment staff.</h4><h4>Duties Continued</h4><h4>Partners with Claims Administration to align QA results with workflow changes, training needs, and performance expectations. Coordinates with Configuration’s system QA team to align operational audit insights with system testing requirements (no ownership of configuration QA). Works with Payment Integrity to validate accuracy of post-pay adjustments and ensure systemic issues are fed into preventive controls. Collaborates with Compliance &amp; Training to ensure QA findings inform training content, SOP updates, and policy interpretation. Supports SVU and the Tiger Team by validating accuracy of complex claim reviews and identifying upstream contributors to identified issues.</h4><h4>Establishes performance metrics, audit schedules, and competency expectations. Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor.&nbsp; Capitalizes on metrics for proactive indicators of risks, issue identification, cross-functional communication, accountability, transparency, and execute continuous operational improvement. </h4><h4>Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.</h4><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.</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 in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience claims operations, claims auditing, claims QA, or complex claims operational functions.</p><p>At least 3 years of experience leading, supervising /managing staff.</p><p><strong>Equivalency:</strong>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.<br><br></p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Hands-on experience conducting claims testing or accuracy audits.</p><p>Deep experience interpreting provider contracts, payment methodologies, and managed care benefit structures.<br><br></p><p>Demonstrated experience with high complexity claims review and RCA.</p><p>Experience supporting or preparing for regulatory audits (DMHC, DHCS, CMS).</p><p>Demonstrated experience analyzing claims defects and validating corrective actions.</p><p><strong>Preferred:</strong></p><p>Coding experience or equivalent knowledge.</p><p>Experience partnering with system configuration teams.</p><p>Experience with quality program design and audit governance.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Deep understanding of standard claims processing systems and claims data analysis.&nbsp;Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.&nbsp;Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards.&nbsp;Advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.</p><p>Advanced analytical and root-cause analysis skills.&nbsp;Deep knowledge of relevant regulatory requirements.&nbsp;Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail.&nbsp;Ability to track and trend the metrics associated with auditor production.&nbsp;Proficient of Microsoft Office suite, including Word, Excel, Teams and PowerPoint.&nbsp;Highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.&nbsp;Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.&nbsp;Ability to present findings to various levels of management, and including stakeholders, across the organization.</p><p>Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.&nbsp;Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.&nbsp;Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Deep understanding of financial principles.&nbsp;Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.&nbsp;Ability to make informed decisions.&nbsp;Strong verbal, written communication and presentation skills.&nbsp;Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges. Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.<br></p><p><strong>Preferred:</strong></p><p>Coding certifications (CPC, CCS) or equivalent knowledge.<br></p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC) or other equivalent Coding Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><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>                    Medical Coding, Claims, Medicare, Medicaid, Data Entry, Healthcare, Insurance, Administrative                                                    </p>

Manager, Claims Quality Assurance

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Manager, Claims Compliance is responsible for ensuring Core Administrative Operations meet federal, state, and contractual regulatory requirements. This position oversees regulatory interpretation, operational compliance monitoring, corrective action oversight, and the development and delivery of operational training across all claims-related functions. The Manager establishes and maintains documentation standards, partners with operational leaders to evaluate compliance risk, and develops training and readiness programs that ensure staff consistently understand rules, follow procedures, and meet regulatory expectations.</p><p>The Manager serves as the primary compliance liaison for Core Administrative Operations, ensuring that regulatory requirements are embedded into workflows, policies, and training. This position partners closely with the key stakeholders to ensure alignment between compliance oversight, audit findings, training programs, corrective action planning, and quality outcomes. The Manager leads a team responsible for training development, operational compliance validation, regulatory change management, policy governance, and operational readiness. The Manager fosters a culture of compliance, accuracy, clarity, and continuous learning across the Core Administrative Operations ecosystem.</p><p>The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendations on the department's strategic planning and/or long-term decision-making.</p><h4>Duties</h4><p>Ensures that Core Administrative Operations has a strong and sustainable compliance foundation.&nbsp; Interprets regulatory guidance, identifies compliance risks, develops training that operationalizes regulatory changes, and builds documentation that ensures accuracy and audit readiness.&nbsp; Strengthens operational integrity, improves adherence to state/federal requirements, and equips staff with the knowledge and tools needed to process claims accurately and consistently through cross-functional collaboration, transparent communication, and structured oversight.</p><p>Monitors compliance with regulatory agencies, NCQA, and contractual requirements related to claims processing, adjustments, disputes, configuration, and payment accuracy. Interprets new and updated regulations, determines operational impacts, and guides leaders in implementing compliant workflows across key stake holders. &nbsp;Oversees compliance monitoring and internal validation activities, ensuring critical regulations (TATs, notices, interest, benefit/payment rules, documentation) are consistently met. Serves as subject-matter expert on regulatory and contractual requirements affecting claims and related administrative functions. Partners with the key stakeholders to ensure compliance findings are integrated into testing programs, CAP validation, and quality standards.</p><p>Designs, implements, and oversees comprehensive operational training programs across cross functional teams. &nbsp;Develops training curricula for benefit/authorization interpretation, regulatory updates, pricing/reimbursement requirements, provider contract terms, system logic impacts, and other operational topics. Ensures training incorporates regulatory expectations, audit findings, corrective action themes, and emerging rules. Maintains an enterprise training repository (SOPs, desk procedures, job aids, reference guides) to ensure consistent understanding and execution. Provides onboarding training, cross-training programs, and targeted training for new systems, regulatory changes, and operational enhancements. Partners with key stakeholders to ensure staff have the knowledge required to maintain accuracy in a highly regulated environment.</p><h4>Duties Continued</h4><p>Oversees creation, maintenance, and governance of policies, procedures, desk-level workflows, and job aids across Core Admin Ops. Ensures documentation is aligned with current regulatory requirements, contractual obligations, and operational processes. Maintains structured documentation approval processes and version control to support audit readiness and compliance transparency. Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards.</p><p>Leads operational readiness planning for regulatory or contractual changes affecting claims payment, provider reimbursement, data requirements, notices, timelines, and related administrative rules. Collaborates with key stakeholders to identify impacts, design compliant solutions, and update training/materials. Develops and manages implementation plans for required changes, ensuring consistency across teams and sustainable compliance. Supports internal and external audits by preparing documentation, participating in sample review, and coordinating with QA and operational leaders. Tracks regulatory trends and proactively identifies potential compliance risks or exposure areas.</p><p>Develops and oversees corrective actions related to compliance gaps, operational deficiencies, and audit findings. Ensures corrective actions incorporate training, policy updates, and process changes to drive sustainable improvement. Partners key stakeholder to validate Corrective Action Plan (CAP) effectiveness through testing, monitoring, and data-driven assessments. Tracks patterns of compliance gaps and collaborates with operational leaders to implement preventive improvements.</p><p>Serves as the primary compliance advisor to operational leaders within cross functional business units. Supports management with regulatory interpretation, operational analysis, compliance risks, and recommended mitigation strategies. Represents Claims Compliance in governance meetings, operational readiness discussions, and regulatory working groups. Partners with Analytics and operational reporting teams to monitor compliance metrics, operational adherence, and trend analyses.</p><p>Manages, leads, trains, and develops a team responsible for training, documentation, compliance monitoring, and regulatory interpretation. Ensures staff maintain deep working knowledge of regulatory requirements and operational processes. Builds a culture grounded in data integrity, critical thinking, and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement. Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.<br>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 in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience in claims compliance, regulatory oversight, or related experience in a managed care environment.</p><p>At least 4 years of experience leading, supervising/managing staff.</p><p><strong>Equivalency:</strong>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p>Experience with claims processing, adjustments, payment methods, and associated core administrative operations.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience developing training programs or documentation for claims or other administrative operations.</p><p>Deep experience interpreting regulations, provider contracts, payment methodologies, and managed care benefit structures.</p><p>Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.</p><p>Experience supporting or preparing for regulatory audits ((Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)) including corrective action planning.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong operational understanding, and the ability to translate complex regulatory and contractual requirements into practical, operational execution.&nbsp;</p><p>Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards (Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)/ Diagnosis Related Group (DRG)).</p><p>Strong understanding of federal/state regulatory frameworks governing claims.</p><p>Exceptional ability to translate regulatory requirements into operational training and documentation.</p><p>Strong analytical, problem-solving, and compliance monitoring skills.</p><p>Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.</p><p>Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail.</p><p>Proven ability to work collaboratively and influence across multiple functional areas.</p><p>Proficiency of Microsoft Office suite, including Word, Excel, Teams and PowerPoint.</p><p>Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Strong verbal, written communication and presentation skills.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified HealthCare Compliance (CHC)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><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>                    Claims, Medicaid, Medicare, Insurance, Healthcare                                                    </p>

Manager, Claims Compliance

<p><b>Salary Range:&nbsp;</b>&nbsp;$60,778.00&nbsp;(Min.) -&nbsp;$75,950.00&nbsp;(Mid.) -&nbsp;$91,166.00&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 Workforce Management (WFM) Analyst II supports the operations by forecasting workload, planning staffing, creating schedules, and monitoring real-time performance of contact center and back-office production queues to ensure service level goals are met. This position uses data analysis, workforce tools, and cross-team collaboration to optimize resource allocation and enhance customer experience.</p><h4>Duties</h4><p>Analyzes historical workload data to develop short-, mid-, and long-term volume forecasts. Builds staffing models to identify required headcount based on service levels and department specific targets. Tracks forecast accuracy and recommends adjustments to improve planning precision.</p><p>Creates schedules aligned with forecasted volumes. Manages schedule changes, shift bids, rotations, Personal Time Off (PTO) allocations, and offline scheduled activities. Ensures optimal staffing coverage to balance service quality and cost efficiency.</p><p>Monitors real-time workload queue performance and staffing levels. Recommends and executes intraday actions to maintain service targets. Communicates operational impacts and escalations to department leadership.</p><p>Prepares daily/weekly/monthly productivity and performance reports. Identifies trends and provides analysis to support process improvements and operational decisions. Conducts root-cause analysis for service level misses or staffing issues.</p><p>Maintains WFM systems, ensuring accurate configuration and data integrity. Improves workflows through automation, reporting enhancements, and best practices. Supports new initiatives, product launches, and volume-impacting changes with data-driven insights.</p><p>Supports skilling activities to respond to real-time workload queue conditions.</p><p>Uses established guidelines, process exception requests as submitted by contact center agents and supervisors within the assigned timelines. Processes exceptions to schedules to support training, coaching and meeting requests while ensuring that there is adequate coverage for all contact center channels.</p><p>Performs 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><strong>Required:</strong></p><p>At least 2 years of workforce management experience in a contact center environment.</p><p>Extensive experience with forecasting and scheduling activities.</p><p>Demonstrated experience finding multiple solutions to complex problems.</p><p>Strong experience and understanding of staffing, work queues, and performance measurements.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Knowledge of WFM tools.Ability to interpret WFM data to assist with determining staffing needs.</p><p>Strong analytical and problem-solving skills.</p><p>Strong attention to detail and accuracy skills.</p><p>Ability to learn new systems quickly with minimal support.</p><p>Proficient skills in Excel (formulas and pivot tables).</p><p>Proven ability to meet goals and deadlines.</p><p>Ability to manage multiple priorities and tasks in a fast-paced environment.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><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>                    HR, Human Resources                                                    </p>

Workforce Management Analyst II

<p><b>Salary Range:&nbsp;</b>&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 Customer Engagement and Experience Member Advocate III serves as a high-level resource and member support specialist within L.A. Care’s Customer Engagement and Experience operations. This position advocates and assists members in navigating their health plan benefits, accessing care, resolving issues, addressing waste and abuse, and connecting to community, clinical, and social services.</p><p>The Customer Engagement and Experience Member Advocate III handles complex, sensitive, or escalated cases. Provides guidance to other advocates. &nbsp;Collaborates across departments to improve the member experience. This position plays a key role in supporting retention, satisfaction, and access to care for our underserved population. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Assists members with complex benefit questions, care navigation challenges, grievances, access to services, and issue resolution. Conducts high-touch outreach to support vulnerable or high-risk populations, including seniors, individuals with chronic conditions, and members with unmet social needs. Serves as a subject matter expert for benefit interpretation, care coordination pathways, and service workflows. Resolves escalated inquiries from customer service, care management, and provider relations.</p><p>Helps members understand coverage, Primary Care Physician (PCP) selection, referrals, authorizations, and healthcare system processes. Connects members to community resources related to housing, food, transportation, financial assistance, behavioral health, and other social determinants of health (SDoH) needs. Coordinates with cross-functional key stakeholders to remove barriers to care.</p><p>Supports member engagement initiatives such as health literacy outreach, preventive care reminders, redetermination support, and quality-improvement campaigns (e.g., Healthcare Effectiveness Data and Information Set (HEDIS), California Association of Health Plans (CAHPS)). Participates in member experience programs focused on improving satisfaction, retention, and service outcomes. Documents member feedback and identifies recurring pain points for operational improvement.</p><p>Works closely with cross-functional key stakeholders to address member needs. Assists with complex cases requiring multi-department coordination. Serves as a representative for Member Advocacy on workgroups or improvement projects.</p><p>Accurately documents all member interactions, interventions, and referrals in the plan’s systems. Escalates potential quality-of-care issues, safety concerns, or compliance risks to appropriate teams. Maintains confidentiality in accordance with Health Insurance Portability and Accountability Act (HIPAA) and managed care regulations. Supports audit readiness through timely, accurate, and complete documentation.</p><p>Apply subject matter expertise in evaluating business operations and processes. Identify areas where technical solutions would improve business performance. Consult across business operations, provide mentorship, and contribute specialized knowledge. Ensure 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. Provide training and recommend process improvements as needed.</p><p>Performs 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 in Healthcare or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience in member services, advocacy, care coordination, customer service, or healthcare navigation.</p><p>Experience working with vulnerable, underserved, and culturally diverse populations.</p><p>Experience resolving individual cases with regulatory state agencies.</p><p><strong>Preferred:</strong></p><p>Experience in Medicaid, Medicare, or managed care environments strongly preferred.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of health plan benefits, medical terminology, and the healthcare delivery system.</p><p>Excellent communication, problem-solving, and conflict-resolution skills.</p><p><strong>Preferred:</strong></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.&nbsp;&nbsp;</p><p>Ability to handle sensitive and complex member issues with compassion and professionalism.</p><p>Knowledge of community and social service resources.</p><p>Proficiency with CRM systems, case management tools, and documentation standards.</p><p>Strong organizational skills and ability to manage multiple priorities.</p><p>Knowledge of healthcare regulations and policies and procedures.</p><p>Excellent public speaking/public presentation 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><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>                    Medicaid, Medicare, Behavioral Health, Social Services, Healthcare, Service                                                    </p>

Customer Engagement and Experience Member Advocate III

<p><b>Salary Range:&nbsp;</b>&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 Customer Engagement and Experience Member Advocate III serves as a high-level resource and member support specialist within L.A. Care’s Customer Engagement and Experience operations. This position advocates and assists members in navigating their health plan benefits, accessing care, resolving issues, addressing waste and abuse, and connecting to community, clinical, and social services.</p><p>The Customer Engagement and Experience Member Advocate III handles complex, sensitive, or escalated cases. Provides guidance to other advocates. &nbsp;Collaborates across departments to improve the member experience. This position plays a key role in supporting retention, satisfaction, and access to care for our underserved population. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Assists members with complex benefit questions, care navigation challenges, grievances, access to services, and issue resolution. Conducts high-touch outreach to support vulnerable or high-risk populations, including seniors, individuals with chronic conditions, and members with unmet social needs. Serves as a subject matter expert for benefit interpretation, care coordination pathways, and service workflows. Resolves escalated inquiries from customer service, care management, and provider relations.</p><p>Helps members understand coverage, Primary Care Physician (PCP) selection, referrals, authorizations, and healthcare system processes. Connects members to community resources related to housing, food, transportation, financial assistance, behavioral health, and other social determinants of health (SDoH) needs. Coordinates with cross-functional key stakeholders to remove barriers to care.</p><p>Supports member engagement initiatives such as health literacy outreach, preventive care reminders, redetermination support, and quality-improvement campaigns (e.g., Healthcare Effectiveness Data and Information Set (HEDIS), California Association of Health Plans (CAHPS)). Participates in member experience programs focused on improving satisfaction, retention, and service outcomes. Documents member feedback and identifies recurring pain points for operational improvement.</p><p>Works closely with cross-functional key stakeholders to address member needs. Assists with complex cases requiring multi-department coordination. Serves as a representative for Member Advocacy on workgroups or improvement projects.</p><p>Accurately documents all member interactions, interventions, and referrals in the plan’s systems. Escalates potential quality-of-care issues, safety concerns, or compliance risks to appropriate teams. Maintains confidentiality in accordance with Health Insurance Portability and Accountability Act (HIPAA) and managed care regulations. Supports audit readiness through timely, accurate, and complete documentation.</p><p>Apply subject matter expertise in evaluating business operations and processes. Identify areas where technical solutions would improve business performance. Consult across business operations, provide mentorship, and contribute specialized knowledge. Ensure 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. Provide training and recommend process improvements as needed.</p><p>Performs 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 in Healthcare or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience in member services, advocacy, care coordination, customer service, or healthcare navigation.</p><p>Experience working with vulnerable, underserved, and culturally diverse populations.</p><p>Experience resolving individual cases with regulatory state agencies.</p><p><strong>Preferred:</strong></p><p>Experience in Medicaid, Medicare, or managed care environments strongly preferred.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of health plan benefits, medical terminology, and the healthcare delivery system.</p><p>Excellent communication, problem-solving, and conflict-resolution skills.</p><p><strong>Preferred:</strong></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.&nbsp;&nbsp;</p><p>Ability to handle sensitive and complex member issues with compassion and professionalism.</p><p>Knowledge of community and social service resources.</p><p>Proficiency with CRM systems, case management tools, and documentation standards.</p><p>Strong organizational skills and ability to manage multiple priorities.</p><p>Knowledge of healthcare regulations and policies and procedures.</p><p>Excellent public speaking/public presentation 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><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>                    Behavioral Health, Social Services, Medicaid, Medicare, Healthcare, Service                                                    </p>

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