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<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 (CE&amp;E) Project Manager II manages, assesses and executes strategies based on identified stakeholder needs, as well as regulatory requirements. The position is responsible for overseeing the department's outreach and engagement projects aligned with organizational strategic goals and department initiatives. The position will work closely and aid each CE&amp;E vertical by creating project documentation and workflows, managing interdepartmental traffic/requests for CE&amp;E department project support, maintaining vertical SharePoint sites, and developing and maintaining a master calendar of CE&amp;E projects, activities and regulatory timeframes. The position will participate in the development, monitoring, and up keep of all Desk Level Procedures and Policies and Procedures, ensuring an annual review is implemented and completed. Works closely with the CE&amp;E Technical Writer to ensure processes and procedures are accurately configured in the On Line Help Tool and assist the CE&amp;E Program and Initiatives Managers with project execution and implementation.</p><h4>Duties</h4><p>Partners, supports and collaborates with key stakeholders in scoping, implementing, evaluating and managing portfolio of assigned projects.&nbsp; Oversees the development and strategic implementation of multimodal member communications programs for all Line of Business (LOBs), including product/service-specific campaigns across multiple distribution channels.</p><p>Collaborates with and leads cross-functional project teams to address project requirements, including developing/tracking deliverables and maintaining regular on going communication with project stakeholders; develop and maintain Desk Level Procedures/Policies and Procedures. Maintain knowledge of product line contracts, regulations, requirements, and obligations and ensure responsible business units are compliant with requirements.</p><p>Identifies, recommends and applies business solutions derived from research and analysis findings for all assigned CE&amp;E projects/programs. Documents project/program and business workflows and processes, project plans and meeting minutes with input from key stakeholders and project team members. Lead process evaluation and improvement activities and analysis and research activities in areas such as customer satisfaction and best practices.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business Administration or Healthcare AdministrationIn 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 3 years of experience in project management with the demonstrated experience on the following list of stated knowledge, experience and/ or skills.</p><p>Experience in developing work plans/documents, working in databases.</p><p><strong>Preferred:&nbsp; </strong></p><p>Previous experience in project/program management with health plan or provider services/operations and knowledge of Medicaid managed care.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong interpersonal, written and verbal communication skills, and work collaboratively and independently within the established guidelines, policies, and procedures.</p><p>Detailed oriented and excellent organizational skills.&nbsp;</p><p>Proficiency in Microsoft Office applications and Visio.</p><p>Facilitation of discussions regarding member communication processes.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Project Management Professional (PMP)<h4>Required Training</h4><h4>Physical Requirements</h4><h4>Additional Information</h4><p>Required:</p><p>Bachelors Degree in Business Administration, Healthcare Administration, or Public Health.</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>                    Healthcare Administration, Medicaid, Public Health, Healthcare                                                    </p>

L.A. Care Health Plan

Customer Engagement and Experience Project Manager II

<p><b>Salary Range:&nbsp;</b>&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&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 Director, Payment Integrity defines the payment integrity operating model.&nbsp; As owner, is accountable for prevention, governance, analytics, risk reduction and sustained accuracy across all prepay and post pay activity.&nbsp; This position is responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program. This position ensures the accuracy of provider payments, minimized inappropriate spend, and strengthens preventive and detective controls across all lines of business. The Director oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, coordination of benefits (COB), third-party liability (TPL), and analytical review of billing and payment patterns.</p><p>The Director sustains a Payment Integrity operating model that prevents incorrect payments before they occur, improves the reliability of claims processing through strong upstream controls, identifies systemic issues contributing to payment errors, and drives operational, configuration, or provider-facing changes that improve accuracy over time. This leader partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.</p><p>The Director leads a multi-functional team that includes internal data mining, clinical review, overpayment recovery, prospective pre-payment programs, and vendor management. The Director is responsible for building analytic and operational rigor, embedding standardized processes, and fostering a culture of accountability, operational consistency, and continuous improvement.</p><p>This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Develops strategic plans, drives change and influences critical business outcomes.</p><h4>Duties</h4><p>Strengthens accuracy, prevents financial leakage, and ensures upstream and downstream controls operate as a cohesive system. Refines and enhances disciplined processes, improves the sustainability of controls, and leverages data to identify and mitigate risks before they impact members, providers, or financial performance. Through cross-functional collaboration, structured execution, and proactive problem-solving, enhances the organization’s ability to manage medical spend responsibly and ensure accurate, compliant payment outcomes.</p><p>Develops and executes the Payment Integrity strategy, ensuring alignment with enterprise financial, operational, and regulatory priorities. Leads a comprehensive operating model that integrates pre-pay, post-pay, clinical editing, cost-avoidance, data mining, recovery operations, COB, and TPL functions.&nbsp; Designs and maintains governance frameworks, policies, workflows, and quality standards that strengthen preventive controls and reduce rework.&nbsp; Ensures consistent application of rules, benefit interpretation, pricing methodologies, and contract terms across all Payment Integrity activities.</p><p>Oversees the development and implementation of pre-payment controls including clinical editing, code auditing, configuration recommendations, automated and algorithm-based edits, and pre-pay clinical and non-clinical reviews. &nbsp;Partners with cross functional teams to implement upstream changes that prevent recurring payment errors and reduce operational burden.&nbsp; Leads initiatives that increase automation, improve first-pass accuracy, and reduce the volume of post-pay recoveries.</p><p>Oversees identification, validation, and recovery of overpayments across solicited and unsolicited sources, ensuring accuracy, transparency, and regulatory compliance.&nbsp; Leads recovery operations, including provider outreach, appeals support, repayment management, and reconciliation of recovery outcomes. Ensures post-pay findings feed into proactive improvements and preventive interventions, reducing future inappropriate payments.<br><br><br></p><h4>Duties Continued</h4><p>Directs internal data mining and analytical review functions to identify billing anomalies, emerging risk patterns, and cost avoidance opportunities.&nbsp; Partners with Analytics leaders to develop predictive models, dashboards, and trending tools that support smarter interventions and program scalability.&nbsp; Translates analytical insights into operational or system changes that reduce leakage and strengthen the accuracy of initial payment decisions.<br>Oversees COB and TPL programs to ensure correct payer order, maximize cost avoidance, and support regulatory reporting requirements.&nbsp; Ensures timely, accurate, and complete responses to inquiries from DHCS or other regulatory bodies.&nbsp; Strengthens processes to reduce inappropriate payments that result from eligibility, coordination, or primary payer errors.</p><p>Manages relationships with Payment Integrity vendors, ensuring contract compliance, performance against SLAs, timely implementation of new programs, and accurate financial reconciliation.&nbsp; Assesses vendor performance and identifies opportunities to optimize or expand program impact.&nbsp; Ensures vendor partners follow appropriate standards, quality controls, and documentation expectations.</p><p>Ensures Payment Integrity processes meet all regulatory and contractual requirements across Medicaid, Medicare, Commercial, and Exchange lines of business.&nbsp; Leads or supports responses to audits, inquiries, corrective action plans, and regulatory reviews related to payment accuracy.&nbsp; Partners with QA to validate accuracy and consistency of Payment Integrity findings, recoveries, and interventions.</p><p>Collaborates with Claims Administration, Configuration, Provider Network Management, EDI, Compliance, and Finance to address systemic issues and improve end-to-end payment outcomes.&nbsp; Advises leadership and internal partners on payment accuracy trends, root-cause drivers, provider impact, and mitigation strategies.&nbsp; Builds strong relationships with provider partners and communicates clearly on payment rules, system behaviors, and corrective actions.</p><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively.&nbsp;</p><p>Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.&nbsp; Identifies and actualizes enhancements to support company vision.&nbsp;</p><p>Develops and maintains relationships with key stakeholders.&nbsp; Leads discussions on policy operationalization and oversees key policy perspective sharing.</p><p>Oversees succession planning to build technical expertise and operational consistency.&nbsp; Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><h4>Perform other duties as assigned.</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 7 years of deep experience in Payment Integrity, Fraud/Waste/Abuse prevention, Claims Accuracy, Medical Cost Containment, and/or other Program Integrity functions.</p><p>At least 5 years of experience leading, supervising and/or managing staff.</p><p>Demonstrated experience in pre-pay and/or post-pay program oversight, cost-avoidance strategies, recovery operations, clinical editing, or data mining.</p><p>Experience working with and interpreting provider contracts, benefit structures, pricing methodologies, and Medicaid/Medicare regulatory requirements.</p><p><strong>Preferred:</strong></p><p>Experience developing and overseeing COB/TPL programs.</p><p><br>Experience engaging with regulators, responding to audits, and overseeing and managing vendor partners.</p><p><br>Experience implementing predictive analytics or algorithm-based Payment Integrity solutions.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.</p><p>Deep understanding of payment accuracy, claim rules, industry coding standards, reimbursement methodologies, and cost-containment strategies.</p><p>Strong analytical, financial, risk-management and problem-solving skills.</p><p>Ability to manage complex workflows, prioritize competing demands, and deliver results in high-volume environments.</p><p>Ability to build strong teams that work effectively together and collaborate across the organization</p><p>Ability to establish and maintain effective working relationships with representatives at provider organizations and with internal stakeholders.</p><p>Ability to interpret and apply complex operating instructions, state and federal regulations, and department/division procedures. Ability to understand, apply, and communicate rules, regulations and guidelines to others.</p><p>Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations.</p><p>Proficiency with Microsoft Office and data/reporting tools.</p><p>Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.</p><p>Demonstrated ability to make sound and timely decisions.</p><p>Demonstrated ability to adapt to changing situations and adjust strategies accordingly.</p><p>Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.</p><p>Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.</p><p>Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.</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, Claims, Medicare, Risk Management, Healthcare, Insurance, Finance                                                    </p>

Director, Payment Integrity

<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 Senior Manager, Claims Adjustments manages all adjustment-related operational workflows, including provider disputes, escalated claim reviews, complex adjustments, and litigation-related claim support. This position ensures that adjustment decisions are accurate, timely, consistent, and fully compliant with state, federal, and contractual requirements. The position functions as the operational leader for all claim adjustments that exceed routine examiner responsibilities and require higher-level investigation or coordination.</p><p>The Senior Manager leads a team of adjustment analysts and dispute specialists, building a culture of accuracy, documentation discipline, transparency, and initiative-taking issue identification.</p><p>The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Manages daily operations for all non-routine claim adjustments, including escalated cases, complex pricing reviews, and benefit or authorization-related adjustments. Ensures that adjustments are accurate, compliant, and completed within regulatory and contractual timeframes.</p><p>Oversees consistent application of payment rules, contract terms, and standardized work instructions. Builds and maintains clear adjustment pathways based on claim type, complexity, and regulatory requirements.</p><p>Oversees provider disputes requiring adjustment, including root-cause analysis and documentation of findings.</p><p>Ensures all provider adjustments meet Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and contractual (TAT) requirements.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Provides operational support for high-profile or complex provider inquiries involving reimbursement, coding, contract terms, or medical policy.</p><p>Manages communication with cross-functional departments and/or teams when needed. Ensures all adjustments are documented accurately and consistently, supporting audit readiness.</p><p>Partners with Compliance to validate adherence to regulatory standards and internal policies. Escalates potential compliance gaps or systemic issues that may require corrective action.</p><p>Partners with Legal to support claim-level discovery, case review, and preparation of adjustment packages.</p><h4>Duties Continued</h4><p>Provides operational insight on benefit application, contract interpretation, and pricing methodology relevant to legal inquiries. Ensures adjustments completed in relation to litigation or legal review are precise and audit ready.</p><p>Collaborates closely with cross-functional departments to resolve adjustment-related dependencies. Communicates root-cause drivers of adjustment volume and advocates for upstream corrections. Ensures adjustment processes are aligned with enterprise standards and system logic.</p><p>Develops reports and dashboards tracking adjustment volume, turnaround performance, accuracy trends, and systemic issues. Identifies trends in adjustment drivers and collaborates on upstream solutions that reduce rework.</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 Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions</p><p>Provides executive summaries for high-risk or high-complexity adjustment issues.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments.</p><p>Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</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 6 years of experience working in claims, provider disputes, adjustments, or related operational functions.</p><p>At least 5 years of experience in leading, supervising and/or managing staff</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience in interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Experience managing complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups</p><p><strong>Preferred: </strong></p><p>Experience supporting regulatory audits, legal reviews, or corrective action plans.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules.</p><p>An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.</p><p>Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS).</p><p>Strong analytical and decision-making skills for complex claim scenarios.</p><p>Ability to provide reporting requirements based on processes and/or regulatory requirements</p><p>Proven critical thinking skills and ability to translate knowledge to the department</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</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 exceptional 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, including executive communication.</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>                    Medicaid, Claims, Medicare, Healthcare, Insurance                                                    </p>

Senior Manager, Claims Adjustments

<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 Senior Manager, Appeals &amp; Grievance (A&amp;G) Center of Quality &amp; Excellence is a strategic leader responsible for driving operational performance, regulatory compliance, service quality, and continuous improvement across all appeals and grievance functions. This position ensures accuracy, completeness, compliance, and audit-readiness of grievance, appeal, and State Fair Hearing case files across all product lines, including Medi-Cal, Medicare, Marketplace, and commercial products. The Senior Manager manages a comprehensive quality and audit program that includes case accuracy audits, documentation integrity reviews, timeliness monitoring, regulatory audit preparation, universe submissions, corrective action management, and governance of policies and standard operating procedures.</p><p>The Senior Manager collaborates closely with a cross-functional management team to identify systemic issues, strengthen internal controls, and ensure sustainable compliance with Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements. The Senior Manager ensures the A&amp;G department maintains the highest standard of documentation quality, operational integrity, and regulatory alignment.</p><p>The Senior Manager Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Strengthens the control environment across A&amp;G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations.</p><p>Manages the A&amp;G quality assurance program, ensuring systematic audits of case accuracy, documentation completeness, decision rationale, classification accuracy, letter quality, and regulatory alignment.</p><p>Oversees validation of issue codes, categories, decisions, and disposition accuracy for grievance and appeal cases across all lines of business.</p><p>Conducts quality reviews of delegated entities and plan partners to ensure contractual and regulatory alignment, coordinating with Provider Network Management as appropriate. Ensures continuous monitoring of documentation quality and supports operational teams in remediation of identified gaps.</p><p>Administers the A&amp;G audit readiness program, ensuring the department maintains sustainable compliance with DHCS, DMHC, CMS, NCQA, and other governing agencies.</p><p>Oversees preparation for all internal, external, and regulatory audits, including universe submissions, case file reviews, evidence packet integrity, corrective action plans, and readiness assessments. Ensures case file integrity through routine audits validating completeness, accuracy, timeliness, and regulatory adherence.</p><p>Oversees timeliness monitoring and reporting, identifying trends and partnering with operational teams to implement timely corrective actions.</p><p>Leads internal mock audits and guides teams through audit-life-cycle activities, from preparation to response to sustainability.</p><p>Partners with cross-functional departments to strengthen control environments and resolve systemic issues. Strengthens the control environment across A&amp;G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations.</p><p>Identifies systemic issues, drives corrective action, supports operational improvement, and ensures A&amp;G maintains continuous compliance. Oversees the development, execution, and monitoring of corrective action plans (CAPs) associated with operational, quality, or regulatory audit findings.</p><p>Monitors CAP performance to ensure timely closure, sustainable outcomes, and ongoing compliance with regulatory expectations. Ensures cross-functional alignment and accountability for quality- and audit-related corrective actions.</p><p>Translates regulatory expectations, operational requirements, and quality standards into dependable, sustainable, and high-performing quality and audit programs. Oversees creation, annual review, and maintenance of policies, procedures, desktop guides, templates, and decision-support tools for A&amp;G activities.</p><p>Ensures compliance with evolving regulatory standards and alignment with enterprise governance and operational workflows.</p><h4>Duties Continued</h4><p>Partners with senior management to validate training effectiveness and ensure process adherence across operational teams.</p><p>Produces and oversees quality, audit, and compliance trend reporting, including timeliness metrics, accuracy outcomes, and recurring error themes.</p><p>Provides data-driven insights and actionable recommendations to A&amp;G leadership, executive leaders, and cross-functional governance committees.</p><p>Maintains quality dashboards and partners with analytics teams to strengthen visibility into operational</p><p>performance and quality indicators.</p><p>Collaborates with cross-functional management teams to resolve root-cause issues and strengthen processes.</p><p>Supports enterprise-level initiatives related to service performance, regulatory compliance, audit preparedness, and operational improvement.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/or executive management to define, prioritize, and develop projects and programs.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Responsible for overseeing and managing the budgets of their respective departments.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.&nbsp; Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Ensures workforce planning supports quality and audit program needs.</p><p>Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</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 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory positions.</p><p>At least 5 years of experience in leading, supervising and/or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience in overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting.</p><p>Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations.</p><p>Experience developing and managing corrective action plans and driving sustainable remediation.</p><p>Experience collaborating with delegated entities, plan partners, or subcontracted networks.</p><p><strong>Preferred:</strong></p><p>Experience with analytic dashboards and visualization tools (Power BI, Tableau).</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Proven ability to lead universe submissions, mock audits, and regulatory audit responses.</p><p>Strong leadership and stakeholder management skills.</p><p>Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care.</p><p>Strong analytical and critical thinking skills, including ability to translate trends into corrective actions.</p><p>Ability to design, implement, and sustain standardized processes and internal control structures.</p><p>Proficiency with Microsoft Office, case management systems, and reporting tools.</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment.</p><p>Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</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>Exceptional verbal, written communication, and presentation skills. Includes executive communication and the ability to translate trends and other findings into actionable recommendations.</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>Lean Six Sigma certification (Green Belt or higher)Project Management Professional (PMP)Program Management Professional (PgMP)<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>                    Medicaid, Medicare, Healthcare                                                    </p>

Senior Manager, Appeals and Grievances Center of Quality and Excellence

<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 Lead Service Liaison position is responsible for supporting daily management functions of the outreach team, helping ensure productivity, quality, and performance targets are met.</p><p>This position serves as the subject matter expert for the execution of member and provider outreach efforts for all lines of business. This position leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.</p><h4>Duties</h4><p>Monitors and facilitates timely contact of members regarding all outreach and retention programs for all lines of business. Provides recommendations for process improvements. Monitors real-time activity and campaign management, as needed. Ensures system of record is functional to provide complete, accurate information. (50%)</p><p>Assists management in ensuring staff provides accurate, timely and quality service to our members and providers, ensuring adherence to all departmental policies, procedures, and standards. Assists with special projects and campaigns that can provide feedback for membership satisfaction. Assists with campaign management functions for outreach efforts across all lines of business. (20%)</p><p>Assists management in providing accurate and timely reports to senior leadership. Performs Quality Assurance functions for vendor outbound campaigns. Interfaces and collaborates with management and stakeholders within and outside of the organization to address and resolve questions, elevate areas of member dissatisfaction, and barriers to care. Assists with identifying and implementing related process and system improvements. (20%)</p><h4>Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Assist management in the oversight of the daily office workflow, recommends enhancements to process and procedures.</h4><h4>Guide the assigned staff in ensuring that the team's work is completed effectively. May assist in the assigning tasks and communicating project goals. Participates in team problem-solving, decision-making, and conflict resolution.</h4><h4>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</h4><h4>Performs other duties as assigned. (10%)</h4><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 customer service experience in a contact center environment, preferably in a managed care plan setting.</p><p>At least 3 months of experience leading a process, program, and/or staff.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong coaching and motivational skills.</p><p>Proficiency with Customer Relationship Management (CRM) systems and dialing platforms.</p><p>Ability to analyze data and make performance-driven recommendations.</p><p>Proficiency in Microsoft Office suite.</p><p>Ability to communication, conflict resolution, and motivational skills.</p><p>Ability to collaborate closely with a team in a collaborative and interactive environment.</p><p>Skilled in fostering teamwork and collaboration.</p><p>Ability to adjust to changing circumstances within the team.</p><p>Good verbal and written communication 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><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>                    Relationship Manager, Customer Service                                                    </p>

Lead Service Liaison

<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 Business Analyst III facilitates business process improvement via the methodical investigation, analysis, review and documentation of functional business specifications. This position manages the requirements development process through the elicitation, analysis, specification and verification of multiple levels of requirements from an end-to-end perspective and supports the ongoing management of the requirements. This position develops report and analysis for the department. It is responsible in communicating and coordinating with IT on a day-to-day department related efforts. The Business Analyst III manages and coordinates the implementation and/or integration of products or new features for clients including client training and provides subject matter expertise (SME) and support of the department's inbound and outbound functions. This position acts as mentor to Business Analysts I/ II.</p><h4>Duties</h4><p>Develop functional and user acceptance test plans and scenarios. Coordinate functional and user acceptance testing by executing the testing strategy, scheduling resources and tracking test performance. Perform data analysis to support evaluation of system defects or to develop requirements for new functionality; assist in various system trouble shooting and balancing and correction efforts including analysis, verification and validation of issues and fixes. Coordinate activities including on-time delivery, testing and production moves.</p><p>Collaborate with I.T. on all department &nbsp;related efforts, including submission of Service Requests and writing BRD's. Coordinate related data requests from internal departments, and/or assist I.T. with definition of criteria. Delegate data and reporting requests to business analysts. Facilitate collaborative system and data design sessions with the user community, technical architecture resources and development resources. Preparation of status updates to enterprise for distribution and communication.</p><p>Work as a technical support and liaison to designated I.T. personnel to provide testing, support and feedback on enhancement requests and regular updates/releases; adhere to release schedules. Provide analytical support for critical corporate initiatives including business function support for system migrations and consolidations, significant business area process improvement projects and complex product installations.</p><p>Demonstrate a high level of subject matter expertise in functional area to bridge business requirements and I.T. solutions; provide technical direction and ensure compliance with best practice solutions. Practice knowledge transfer and foster change management as the organization changes and new skills are required, focusing on team/individual development to be a valued contributor.</p><p>Participate and contribute on the development/ creation of data models and interface design specifications. Support internal/ external stakeholder's roadmap and audits as needed.</p><p><br>Oversee the business process support across multiple client engagements. Communication with internal/ external stakeholders for department's submission requirements. Review submission of data against established benchmarks and coordinate correction and improvement efforts. Monitor timely and accurate outbound data submission to state and federal recipients.</p><h4>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</h4><h4>Perform other duties as assigned.</h4><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><b>Required:</b></p><p>At least 5 years of successful experience in a quantitative role as a Business Analyst, Data Analyst, Programming Analyst, Claims processing, encounter processing.</p><h4>Skills</h4><p><strong>Required:</strong><br>Competent to work at the highest technical level of most phases of systems analysis.</p><p>Excellent verbal and written communication skills.</p><p>Coaching, Mentoring and Teaching skills.</p><p>Teamwork-focused/collaborative work style.</p><p>Demonstrated ability to work successfully on large projects.</p><p>Problem solving skills evidenced by demonstrated results in past positions.</p><p>Ability to work under tight deadlines and handle multiple/detail-oriented tasks.</p><p>Ability to influence at all levels of the organization.</p><p>Proficient in Microsoft Office and Vizio.</p><p><strong>Preferred:</strong><br>Ability to work on other programs such as SharePoint and/ or OneNote</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>Department Specifics:</b></p><p><b>Customer Solution Center Appeals and Grievances:</b></p><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>                    Business Analyst, Claims, Finance, Insurance                                                    </p>

Business Analyst III

<p><b>Salary Range:&nbsp;</b>&nbsp;$171,925.00&nbsp;(Min.) -&nbsp;$232,100.00&nbsp;(Mid.) -&nbsp;$292,274.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Director, Core Administrative Operations is responsible for leading and optimizing L.A. Care’s core administrative functions, including Claims Administration, Payment Integrity, Configuration, Electronic Dara Interchange (EDI) and Quality Assurance. This leader ensures standardized, efficient, accurate, and compliant administrative operations that support high-quality service to providers, members, and internal business partners.</p><p>Steers top-level decision-making and implement initiatives that drive organization's forward. This role drives modernization, operational maturity, and continuous improvement across all core administrative operations, grounded in clear performance expectations, strong governance, and measurable outcomes. The Senior Director collaborates closely with cross functional teams to ensure effective alignment, operational readiness, and sustained performance The Senior Director will oversee a diverse team, ensuring talent development, performance management, and a culture of accountability and operational excellence.</p><p>This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Develops strategic plans, drives change and influences critical business outcomes.</p><h4>Duties</h4><p>Translates strategy into disciplined operational execution. &nbsp;Sets clear expectations, drives cross-functional alignment, and ensures that teams have the tools, data, and governance needed to operate effectively. Collaborates across multiple administrative functions, ensuring workflows, technical changes, performance indicators, and regulatory requirements are understood, synchronized, and executed consistently. Anticipates operational challenges, removes barriers, and strengthens end-to-end processes. &nbsp;Collaborates, plans, proactively problem-solves, leads with transparency, accountability, and focuses on continuous improvement. &nbsp;Elevates operational reliability and positions the organization for sustained success as systems, products, and regulatory standards evolve.</p><p>Leads strategy, operations, and modernization across service areas accuracy, efficiency, and strong control environments. Establishes and manages operational goals, key performance indicators (KPIs)/objectives and key results (OKRs), dashboards, and other metrics to transparently drive consistent performance and compliance.</p><p>Develops and implements standardized workflows, governance structures, and operating procedures.</p><p>Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Directs EDI operations supporting claims submissions, remittance transactions, provider and member exchanges, and other electronic transactions.&nbsp; Drives automation, data accuracy, and improved electronic submission performance. Oversees monitoring and timely resolution of technical issues, rejections, and systemic defects.</p><p>Ensures high-quality adjudication with strong accuracy, first-pass rates, correct benefit application, and compliance with DHCS, DMHC, CMS, Covered California, and NCQA requirement. Oversees configuration of benefits, reimbursement logic, pricing methodologies, and adjudication controls.</p><h4>Duties Continued</h4><p>Collaborates with key stakeholders on prioritization, execution, and validation of configuration updates, system enhancements, and benefit launches.</p><p>Leads strategy and operations related to pre-pay controls, cost-avoidance, post-pay recovery, clinical editing, coordination of benefits (COB), overpayments, and third-party liability (TPL)/subrogation.&nbsp; Partners with cross functional teams to support fraud mitigation and compliance with state and federal requirements.&nbsp; Improves financial accuracy and reduces inappropriate payments through robust controls and audit-ready processes.</p><p>Oversees QA programs across all Core Administrative Operations to ensure ongoing accuracy and compliance.&nbsp; Strengthens control environments through audits, desktop and other standard operating procedures, and performance monitoring.&nbsp; Partners with Compliance, Internal Audit, and Enterprise Risk Management on CAPs, audit responses, remediation plans, and sustainability efforts.</p><p>Oversees the performance of operational vendors in assigned areas. Ensures compliance with service level agreements (SLAs), audit standards, quality expectations, and contractual obligations. Evaluates vendor performance and ensures the implementation of improvements.</p><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.</p><p>Manages budgets and resources effectively. Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.&nbsp; Identifies and actualizes enhancements to support company vision. &nbsp;Identifies and drives change initiatives.</p><p>Collaborates with cross-functional teams to achieve common goals. &nbsp;Leads discussions on policy operationalization and oversees key policy perspective sharing. &nbsp;Represents the company or organization in external interactions. &nbsp;Develops and maintains relationships with key stakeholders.</p><p>Develops and implements communication strategies.</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 9 years of progressively responsible experience leading large operational teams and multi-functional departments in managed care operations, including Claims Administration, Payment Integrity, Configuration, or similar functions</p><p>At least 8 years of management/supervisory experience.</p><p>At least 5 years of experience with Payment Integrity operations.</p><p>At least 5 years of experience with claims system configuration, technical changes, and operational readiness for products, benefits, and system updates.</p><p>Demonstrated successful experience improving operational accuracy, reducing inappropriate payments, and driving regulatory compliance.</p><p>At least 5 years of experience supporting regulatory audits.</p><p><strong>Preferred:</strong></p><p>Experience in government-sponsored programs and large regional plans.</p><p>Experience with vendor management.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.</p><p>Expert knowledge of managed care administrative operations.</p><p><br>Strong strategic, analytical, and financial skills, including the ability to interpret trends, assess risk, and evaluate cost-avoidance opportunities.</p><p>Deep understanding of regulatory requirements for Medicaid (Medi-Cal), Medicare, Marketplace, and commercial lines of business.</p><p>Proven ability to lead in complex, high-volume, highly regulated environments with competing priorities.</p><p>Exceptional communication and stakeholder management skills, with the ability to translate complex concepts into actionable plans.</p><p><br>Exceptional leadership skills and abilities, with demonstrated ability to manage, mentor, and develop multi-level teams.</p><p>Ability to design and implement standardized processes, governance models, and operational controls.</p><p>Strong skills with claims platforms and analytics/reporting tools.</p><p>Proficient with Microsoft Office and data/reporting tools.</p><p>High level of organization, planning, prioritization and attention to detail.</p><p>Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.</p><p>Demonstrated ability to make sound and timely decisions.</p><p>Demonstrated ability to adapt to changing situations and adjust strategies accordingly</p><p>Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.</p><p>Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment</p><p>Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Lean Six Sigma Green BeltLean Six Sigma Black Belt<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>                    Internal Audit, Claims, Medicaid, Medicare, Risk Management, Finance, Insurance, Healthcare                                                    </p>

Senior Director, Core Administrative Operations

<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 Training Delivery oversees end-to-end training programs that prepare customer service representatives to deliver excellent, compliant, and accurate support to L.A. Care members across all lines of business. This position manages and leads a team responsible for content creation, new hire onboarding, upskilling, system training, regulatory training, and continuous learning.</p><p>The Manager partners with key stakeholders to ensure training supports first call resolution, performance goals, regulatory requirements, and member experience standards.</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>Manages the development, coordination, and delivery of training programs for customer service teams, including new hire onboarding, refresher training, upskilling, cross-training, and product updates. Ensures all training content reflects current health plan benefits, state and federal requirements, contact center scripts, systems, and operational workflows. Oversees the creation of training materials, facilitator guides, job aids, and e-learning modules.</p><p>&nbsp;Manages and leads the Training Specialists. Conducts coaching, performance evaluations, and professional development. Promotes a culture of customer engagement, teamwork, high-quality facilitation, and continuous improvement.</p><p>Collaborates with key stakeholders to identify training needs and performance gaps. Participates in business reviews, calibrations, Quality Assurance (QA) trend meetings, and system enhancement discussions. Ensures training supports key metrics such as call quality, first call resolution, accuracy, service levels, compliance, and member satisfaction.</p><p>Guarantees that training programs meet Centers for Medicare and Medicaid Services (CMS), state, National Committee for Quality Assurance (NCQA), Health Insurance Portability and Accountability Act (HIPAA), and organizational compliance standards. Partners with Compliance to develop, schedule, and track mandatory trainings on privacy, fraud/waste/abuse (FWA), and regulatory updates. Maintains audit-ready documentation for training content, attendance, and evaluations.</p><p>Oversees the design and maintenance of course content using adult learning principles. Updates training materials promptly when system changes, benefit updates, or new regulations occur. Ensures consistency of workflow teaching across trainers and training channels.</p><p>Assesses training effectiveness through evaluations, testing, knowledge checks, QA feedback, and post-training performance metrics. Tracks speed-to-competency, new hire performance, and continuous improvement opportunities. Uses data to refine training methods and curriculum.</p><p>Oversees use of Learning Management Systems (LMS) platforms, e-learning software, virtual training tools, and contact center simulation technologies. Recommends new tools or enhancements to improve learner customer engagement and training quality. Supports both in-person and virtual training experiences.</p><p>Supports initiatives that impact customer service performance, such as Consumer Assessment of Healthcare Providers and Systems (CAHPS) and STARS improvement, member experience efforts, new line-of-business launches, and system rollouts. Serves as a subject matter expert for training in cross-functional project teams.</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 training delivery and/or instructional design in a customer service and/or contact center operations environment.</p><p>At least 3 years of experience leading, supervising and/or managing staff.</p><p>Experience leading training teams, projects, initiatives, or cross-functional groups.</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><strong>Preferred:</strong></p><p>Managed care plan (Medicaid, Medicare Advantage, Commercial) experience strongly preferred.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong verbal, written communication and presentation skills.</p><p>Excellent facilitation and presentation skills.</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>Strong competency in adult learning theory and instructional design.</p><p>Strong knowledge and understanding of health plan benefits, contact center service workflows, and regulatory requirements.</p><p>Ability to manage multiple training initiatives in a fast-paced environment. Ability to analyze training data and connect it to performance outcomes.</p><p>Proficiency MS suite skills. Expert LMS systems, e-learning tools, and virtual training platforms skills.</p><p>Strong organizational, project management, and problem-solving skills.</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>Conflict resolution skills with the ability to mediate disputes and resolve conflicts in a fair and constructive manner.</p><p>Must have a deep knowledge and understanding of financial principles. Ability and excellent knowledge 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>Deep knowledge and understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong knowledge and ability 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>                    Learning, Medicaid, Medicare, Human Resources, Healthcare                                                    </p>

Manager, Customer Engagement and Experience Training Delivery

<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 Workforce Management (WFM) Analyst I supports scheduling, forecasting, and real-time monitoring of contact center, back-office and production queues, as well as adherence to schedule activities for department’s staff. This position assists by gathering data, generating reports, monitoring performance, and helping ensure staffing levels meet the demands of the volume.&nbsp;</p><h4>Duties</h4><p>Provides real-time monitoring and management of department’s queues, back-office, and production workload. Prepares reports on updates related to call performance, back-office and production workload, service levels, adherence to schedule, and overall staffing. (45%)</p><p>Assists in creating ad-hoc reports and analysis as requested by department and senior leadership. Documents intraday events and escalates issues to WFM team and department leadership as needed. Monitors adherence to schedule activities and excessive state durations, where applicable. (10%)</p><p>Collaborates with department leaders to address staff behaviors. Recommends real-time schedule changes. Identifies efficiency opportunities. Optimizes scheduled breaks and lunches as resource requirements change. Determines the need for extra work hours and/or early departures. Assess availability for offline functions and approves/denies as required. Reviews and responds to schedule change requests. Assists with the creation of all schedule runs and schedule bids/changes. (10%)</p><p>Supports senior analysts by organizing historical data used for work volume and staffing forecasts. Helps identify patterns or variances in work volume trends. &nbsp;(5%)</p><p>Supports skilling activities to respond to real-time workload queue conditions. (10%)</p><p>Uses established guidelines, process exception requests as submitted by department’s 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 departments channels. (10%)</p><p>Performs other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 2 years of workforce management experience in a contact center environment.</p><p>Demonstrated experience finding multiple solutions to complex problems.</p><p>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>Proficiency in Excel (formulas and pivot tables).</p><p>Analytical and problem-solving skills.</p><p>Strong attention to detail and accuracy.</p><p>Ability to learn new systems quickly with minimal support.</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 I

<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 Senior Manager, Claims Administration provides daily operational leadership for enterprise claims adjudication across all lines of business. This position is responsible for ensuring timely, accurate, compliant claim processing through disciplined production management, strong operational controls, and consistent application of claims policies, benefit rules, and contractual requirements.</p><p>The Senior Manager manages a team to deliver predictable throughput, high first-pass accuracy, strong auto-adjudication rates, and consistent cycle-time performance. The position ensures operational readiness for benefit changes, system updates, regulatory modifications, and cross-functional dependencies while continuously improving process quality and reducing rework. The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><p>This position serves as a subject matter expert in claims adjudication logic, benefit structures, regulatory requirements, billing and coding standards, and provider contract application. The Senior Manager builds a high-performing culture grounded in accuracy, accountability, standardization, continuous improvement, and service excellence.</p><h4>Duties</h4><p>Oversees the daily mechanics of claims production and ensures a controlled, disciplined, and highly reliable operational environment. Responsible for translating enterprise expectations into consistent frontline execution, maintaining a strong control environment, identifying emerging risks quickly, and building upstream partnerships that drive long-term operational maturity. Ensures claims operations are stable, predictable, and aligned to organizational goals.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Oversees day-to-day adjudication operations, ensuring a controlled, disciplined, and exceptionally reliable operational environment that is timely, accurate, and high-quality output by L.A. Care staff and external vendors, as necessary. Manages staff to consistently meet or exceed productivity, quality, and inventory performance targets.</p><p>Ensures all claims are processed within Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Covered California and contractual turnaround requirements.</p><p>Establishes clear routing, triage, and prioritization models to balance workloads and avoid bottlenecks. Promotes operational discipline around standard operating procedures, configuration updates, and quality checkpoints.</p><p>Monitors daily, weekly, and monthly inventory at the claim, queue, and examiner level to anticipate risk and maintain a stable production environment.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Conducts structured production meetings with staff to review performance trends, quality indicators, and backlog prevention plans.</p><p>Identifies systemic constraints and drives timely mitigation through collaboration with cross-functional departments and stakeholders.</p><p>Oversees planning and execution during peak periods (open enrollment, benefit year-end/start, provider contract updates).</p><p>Partners with cross-functional departments to monitor and improve first-pass accuracy and aims to remove rework. Ensures examiners correctly apply benefits, coding, pricing, and provider contract terms.</p><p>Identifies claim types or provider groups with chronic accuracy issues and drives upstream corrections.</p><p>Manages initiatives to improve auto-adjudication rates through system corrections, routing refinement, and reduction of manual touchpoints. Ensures examiners receive timely, accurate updates on benefit changes, pricing methods, and new rules.</p><p>Acts as a critical operational partner to Configuration and Information Technology (I.T.) for system updates, benefit loads, provider contract implementations, and code-set changes. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Participates in User Acceptance Testing (UAT) planning, test case development, operational validation, and go-live readiness for system changes affecting claims.</p><p>Identifies system behavior issues impacting adjudication and ensures prompt ticket creation, escalation, monitoring, and resolution.</p><h4>Duties Continued</h4><p>Ensures examiners receive clear, concise operational guidance tied to configuration updates and policy changes.</p><p>Engages with Enrollment &amp; Eligibility to resolve data discrepancies impacting member benefits or provider assignments.</p><p>Partners with Provider Network on contract load timing, unclear terms, and pricing interpretation issues.</p><p>Coordinates with Utilization Management on authorization-related adjudication issues and utilization policy questions.</p><p>Collaborates with Payment Integrity to leverage findings that require upstream claims-processing adjustments.</p><p>Aligns closely with the senior leadership to ensure seamless handoffs and minimal rework.</p><p>Oversees creation and maintenance of daily production reports, dashboards, and forecasting tools. Uses data to analyze examiner performance, inventory patterns, quality trends, and root-cause drivers of errors. Uses analytical insights to develop operational plans that reduce cycle time, rework, and cost.</p><p>Provides executive-level reporting on throughput, quality, aging, inventory at risk, and operational health.</p><p>Ensures standard operating procedures (SOPs), desktop procedures, workflows, training materials, and job aids are current, accurate, and consistently used across the operation.</p><p>Creates feedback loops with cross-functional departments to update procedures based on new rules or system changes. Ensures staff have clarity on benefit interpretation, contract logic, bundling/unbundling rules, and pricing methodologies.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</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 6 years of experience working in claims operations, provider disputes, adjustments, or related operational functions.</p><p>At least 5 years of experience in leading, supervising and or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Experience handling complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy.</p><p>Experience working with Coordination of Benefits (COB) and Third-Party Liability (TPL) claims in a managed care setting.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p><strong>Preferred: </strong></p><p>Experience supporting regulatory audits, legal reviews, or corrective action plans.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.</p><p>Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules.</p><p>An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.</p><p>Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS).</p><p>Exceptional written and verbal communication skills, including executive communication.</p><p>Strong analytical and decision-making skills for complex claim scenarios.</p><p>Ability to provide reporting requirements based on processes and/or regulatory requirements.</p><p>Proven problem-solving skills and ability to translate knowledge to the department.</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</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><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>

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