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<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, Category Management and Procurement manages and leads the development and execution of multi-year category strategies and implementation of the overall category management and procurement processes for multiple categories and commodities. This position manages continuous improvement and governance of the L.A. Care source-to-pay process. The Manager works closely with key stakeholders and cross-functional teams in developing and executing category plans, strategic sourcing events, supplier performance management (scorecards/quarterly business reviews).</p><p>The Manager is an expert on all category management, procurement, and relationship management requirements and processes.&nbsp; The position leads and provides consultation to other cross-functional teams with executing cost reduction and related activities across the enterprise. The Manager ensures that the team's collective efforts deliver measurable value (savings, cost avoidance, risk reduction, and service improvements), reduce request for proposal (RFP) and contract cycle time, and increase customer service in support of optimizing L.A. Care operations. This position interfaces with internal and external stakeholders.&nbsp;</p><p>This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; The Manager also stewards adherence to procurement policy, contracting standards, and audit readiness across assigned categories. Participates and makes recommendation on the department's strategic planning and/or long-term decision-making.</p><h4>Duties</h4><p>Manages and leads the overall category management and procurement process to ensure high-value execution and integrity of all vendor relationships, pricing and contracts within L.A. Care source-to-pay. Oversees the development and execution of category strategies that align with organizational priorities and deliver measurable savings, efficiency, and compliance. Leverages and optimizes source-to-pay (S2P) systems to improve transparency, accuracy, and cycle time. Ensures vendor data integrity, pricing accuracy, and timely contract execution. Develops requirements, reports, and staff training that reinforce continuous improvement and effective use of procurement systems.</p><p>Manage and develops 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. Ensures staff are proficient in category management methodologies, procurement policies, and S2P tools. Provides guidance, feedback, and escalation support to enable effective decision-making and issue resolution. Responsible for reporting, budgeting, and policy implementation.</p><p>Manages complex, cross-functional sourcing and contracting projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Leads Vendor Selection Process/Request for x (RFxs) and negotiations on select high value vendor contracts from cross-functional teams and provides consultative expertise to the team on other vendor RFxs. Ensures documentation, evaluation criteria and award decisions are compliant, transparent and aligned with L.A. Care standards.</p><h4>Duties Continued</h4><p>Plans, implements and refines systems and procedures to maximize operating efficiency and achieve strategic priorities.</p><h4>Acts as a subject matter expert (SME) for cross-functional teams on proper category management and procurement execution that balances risks and flexibility.&nbsp; Ensures end-to-end source-to-pay process complies to L.A. Care policies while incorporating best practice for effectiveness, efficiency, and better customer service. Implements end-to-end category management and procurement procedures that are compliant to L.A. Care policies and meet L.A. Care's objectives. Ensures category management and procurement procedures and training materials complement procurement processes.&nbsp; Drives continuous process improvement, automation and adoption of best-practice sourcing governance.</h4><h4>Partners with internal departments to develop effective contract processes, tools, and standard procedures while leveraging the contract management system to its fully extent possible. Responsible for safeguarding the acceptable contract clauses, language, templates, and tools pre-approved by the legal team. Collaborates with key stakeholders to manage risk, maintain compliance and improve contract quality and turnaround time.</h4><h4>Leads and facilitates formal meetings with senior internal staff in developing strategic and tactical plans for category management, vendor relationship management, savings opportunities and/or RFx/contracting strategies that allow L.A. Care to function more effectively. Performs vendor contract inventory analysis and reporting, including contracts expirations, spend and compliance data, for review.&nbsp; These insights inform category plans, sourcing pipelines and vendor consolidation opportunities to strengthen vendor performance and ensure ongoing contract compliance.<br><br>Performs other duties as assigned.</h4><h4>Education Required</h4>Bachelor's Degree in Business or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of relevant experience managing the full contract lifecycle for service-related categories and commodities.</p><p>At least 4 years of experience in leading, supervising, and/ or managing staff, whether directly or indirectly.</p><p>Experience drafting, negotiating, red lining, finalizing and managing complex supplier agreements for a wide variety of goods and services.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong legal and business acumen with demonstrated ability to manage complex negotiations and relationships.&nbsp;Excellent written and verbal communication and presentation skills to secure most favorable terms, prices and/services levels and contract terms.&nbsp;Ability to provide direction to team members to execute category management, procurement, and contract efforts with outside vendors.&nbsp;Ability to negotiate and manage relationships and contracts with outside vendors that are in the best interests of L.A. Care.&nbsp;Tactful, diplomatic in implementing new processes, procedures, and systems across L.A. Care and ability to convince staff and management why changes are needed. Skilled in driving and integrating organizational change across all levels.&nbsp;Must be proactive, resourceful, and able to find alternative solutions to deliver results.&nbsp;Demonstrated ability to communicate, problem solve, and work effectively with business, procurement and legal professionals.&nbsp;Ability to be consultative to internal stakeholders on developing the best category management and strategic sourcing (including contract) options.&nbsp;Excellent organizational skills with the ability to manage multiple projects.&nbsp;Strong internal stakeholder management skills: capacity to listen, build trusting relationships in all levels of the organization, understand and capture stakeholder's needs and deliver effective solutions.&nbsp;Good knowledge of legal environment related to purchasing contracts and framework agreements.&nbsp;Strong analytical skills, with keen understanding of relevant cost drivers.&nbsp;Demonstrated ability to select, manage, develop and coach others.&nbsp;Persuasion Skills: Effective negotiator who exhibits high levels of personal integrity and honesty. Skills in planning and coordinating vendor visits and negotiations, and comprehensive knowledge of market conditions. Understanding of the flow and accounting requirements to facilitate document flow and efficiency. Ability to enforce policy compliance.&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. Must have a 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;Demonstrated ability to make informed decisions.&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.</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>Financial Impact: Effective vendor contract negotiation will have a high financial impact and influence because of negotiation of pricing and contract terms.</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>                    Relationship Manager, Performance Management, Customer Service, Human Resources                                                    </p>

L.A. Care Health Plan

Manager, Category Management and Procurement

<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 Senior Manager of Customer Engagement leads the strategy, performance, and operational excellence of the organization’s escalations’ function for all lines of business and across all channels. This role oversees multiple escalation and customer-facing teams, ensuring complex customer issues are resolved promptly, accurately, and with exceptional care. Oversees customer engagement operations across all Community Resource Centers, ensuring the delivery of high-quality service and the cultivation of a welcoming, inclusive environment</p><p>This position is responsible for driving continuous improvement, reducing escalation volume through root cause analysis, enhancing service recovery efforts, and cultivating a high-performing, customer-first culture across the escalation organization. The Senior Manager is accountable for cultivating a collaborative, team-oriented culture that emphasizes continuous quality improvement across the unit and the broader organization. This position ensures a strong focus on customer service efficiency, effectiveness, and quality, while proactively identifying and resolving related issues. The Senior Manager remains attuned to the needs of the populations served and is responsible for recommending, implementing, and/or facilitating enhancements to processes and systems.</p><p>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.&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>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, 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. Builds succession plans, oversees staffing strategies, and manages workforce needs. Fosters a culture of accountability, empathy, and operational excellence.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.&nbsp; 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>Oversees reception desk operations to ensure smooth, efficient, empathetic, and professional service. Implements standard operating procedures for visitor protocols, including resolving escalated issues in a service-oriented manner. Identifies areas for improved efficiency and enhanced experience.</p><p>Leads teams across the Community Resource Center network, ensuring that member-facing staff deliver timely, compliant, and empathetic support. Influences health literacy education, helping members understand health benefits, care instructions, and available supportive services. plays a key role in improving member experience, strengthening community partnerships, and supporting organizational quality initiatives.</p><p>Defines and optimizes end-to-end escalation workflows, including triage, prioritization, case routing, and follow-up. Oversees the timely handling and resolution of high-risk, sensitive, or executive-level customer cases. Collaborates with executive leadership on escalations involving legal, compliance, regulatory and external issues. Ensures alignment of escalation practices with company-wide customer experience strategies.</p><p>Establishes quality standards, call and case review processes, and service recovery protocols. Monitors adherence to compliance requirements. Implements corrective action plans for quality gaps and operational risks. Handles complex or high-profile escalations requiring senior intervention.</p><p>Ensures that all operations comply with applicable regulatory, contractual, and organizational standards. Oversight includes the development and ongoing refinement of departmental policies, procedures, and process documentation.</p><h4>Duties Continued</h4><p>Develops and tracks key performance indicators (KPIs) for escalations. Produces executive-level reporting, insights, and recommendations that influence company decisions. Conducts root cause analysis to identify trends and partners with cross-functional leaders to resolve systemic issues. Guides continuous improvement initiatives to reduce escalation volume and improve customer experience.</p><p>Works closely with cross-functional teams to drive resolution of recurring issues. Represents the escalation organization in leadership meetings and cross-department task forces. Provides actionable feedback to senior leaders on customer pain points and operational gaps.</p><p>Conducts surveys to gather feedback on member experience, service quality, and care outcomes, and translates findings into actionable insights. Partners with other stakeholders to facilitate member focus groups to gather qualitative feedback on programs, services, and barriers to care. Builds and maintains relationships with county agencies and community partners to maintain updated resources and eligibility criteria. Ensures timely follow-up to members to ensure they successfully connect to services. Partners with other stakeholders to create and distribute culturally appropriate materials aligned with health literacy best practices.</p><p>Performs other duties as assigned.&nbsp;</p><h4>Education Required</h4>Bachelor's Degree in Business or Related FieldIn 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 5 years of experience in a contact center, customer support, or escalation environment.</p><p>At least 4 of experience in leading, supervising and/or managing staff.</p><p>Experience in a highly regulated industry.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Demonstrated expertise in high-level customer escalation management.</p><p>Strong analytical, reporting, and decision-making skills.</p><p>Exceptional verbal and written communication abilities, especially for executive-level customer interactions.</p><p>Proficiency with Customer Relationship Management (CRM) and contact center technologies (e.g., Salesforce, Zendesk, Five9, Genesys).</p><p>Strong analytical skills, excellent verbal, written, and interpersonal communication 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 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>Certified Customer Service Professional (CCSP)<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>

Senior Manager, Customer Engagement

<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 Ariba Functional Analyst III will be responsible for supporting the procure-to-pay business processes. This position requires collaboration with various stakeholders, including business groups, the procurement team, and the S/4 team, to analyze, troubleshoot, and resolve production issues impacting the Ariba system, Ariba integration processes, and MM modules. </p><p>The Analyst will also provide support for enhancements and projects related to the Ariba application and procure-to-pay processes within both Ariba and S/4 environments. Core responsibilities include supporting and optimizing existing business processes, as well as contributing to the design, build, and testing of new solutions. Furthermore, the Analyst will provide comprehensive support for the FI/CO applications, including: Ariba to FI integration, Accounts Payable (vendor maintenance, invoicing and payments), Materials Management (Purchase Orders, Purchase Requisitions, logistics Invoicing), Controlling (G/L, Cost Center and Internal Orders maintenance) and Reporting. </p><p>Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Support SAP Ariba suite modules – Ariba Upstream &amp; Downstream (Ariba Sourcing, Contract Management, SLP and Buying &amp; Invoicing).</p><p>Support Ariba Buying &amp; Invoicing production issues with Guided buying capabilities - Tiles, Policies configuration, Tactical sourcing activation.</p><p>Support SAP Ariba supplier enablement – Onboarding, VUF, rules set up, country-based invoice rules, user roles creation in Buyer business network, supplier flight plan, enable end points, default transaction rules.</p><p>Support Ariba sourcing, contract management and Ariba SLP modules.</p><p>Support the Ariba to S/4 integration processes as well as the purchasing, receiving, invoicing, and payment processes in S/4 MM and FICO</p><p>Leverage business and understanding of SAP and accounting expertise to address the business requirements, blueprinting, data analysis, business modeling, unit and integration testing.</p><p>Work with business leaders to define end state procure-to-pay business processes. Works with business departments and process owners in defining functional requirements.</p><h4>Duties Continued</h4><p>Collaborate with business groups to define and develop best practices to standardize processes.</p><p>Analyze business processes and coordinate with the project team to provide solutions to optimize productivity and ensure data accuracy.</p><p>Build process documentation, functional specifications, test scripts and training documentation.</p><p>Establish reconciliation and monitoring processes to ensure system and data accuracy and integrity.</p><p>Provide change management support and direction and train users on new systems and processes.</p><p>Manage projects to roll out applications/business processes to ensure the goals and objectives are accomplish on time and within budget as necessary.</p><p>Work directly with project stakeholders throughout the entire lifecycle of projects to define, design and implement.</p><p>Manage outsourced resources to achieve project goals.</p><p>Prepare project status reports for management and business users.</p><p>Lead system testing effort necessary as part of project deliverables.</p><p>Analyze, troubleshoot, and resolve issues during the project and after it goes live.</p><p>Lead and participate in all the data conversion efforts such as Purchase Orders, vendors, invoices and Contracts.</p><p>Train the SAP team on any knowledge gaps.</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><h4>Experience</h4><p><b>Required:</b></p><p>At least 6 years of experience in SAP FI/CO and ARIBA functional support.</p><p>Experience completing at least 2 ARIBA implementation.</p><p>Experience in the creation of Project and Production Support Documentation such as Functional Specs, Test Scenarios, Test Scripts, Desktop procedures, Business process procedures, and others.</p><p>Experience creating and managing Ariba templates for Contract, Sourcing, Events etc. as per business requirements.</p><p>Experience preparing Ariba User Training guide test scripts. </p><p>Experience in configuring the S/4 Hana and Ariba integration with CIG connectivity.</p><p>Experience in configuring Ariba business network (AN) systems. </p><p><b>Preferred:</b></p><p>Experience with the integration between Procurement, Accounts Payable and Materials Management.</p><h4>Skills</h4><p><b>Required:</b></p><p>Detail oriented and excellent organizational, time and stress management skills.</p><p>Excellent analytical and problem-solving skills.</p><p>Excellent interpersonal skills.</p><p>Excellent communication (verbal, written) and customer-facing skills.</p><p>Willingness to expand knowledge and skills to other technologies and solutions.</p><p>Understand and familiar with SAP FI/CO, and Internal Orders.</p><p>Ability to transfer knowledge and training users.</p><p>Ability to influence at all levels of the organization.</p><p>Knowledge of Microsoft Office Word, Excel and PowerPoint.</p><p>Knowledge of Finance and business operations.</p><p>Knowledge of application testing and ability to design, plan and execute application testing strategies and tactics to ensure software quality throughout all stages of application development.</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>                    Accounts Payable, Finance                                                    </p>

Ariba Functional Analyst III

<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>

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>

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