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Salary Range:&nbsp;&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)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. 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. <h4>Job Summary</h4>The Manager, Appeals &amp; Grievances (A&amp;G) &amp; General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals &amp; Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&amp;G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies &amp; Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards. The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement.This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals.Manages all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.&nbsp;<h4>Duties</h4>Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances.Responsible for timely daily operations in the A&amp;G Clinical Services Unit and other general operations units. &nbsp;Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with cross-functional departments &nbsp;to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate. &nbsp;Lead, participate and provide representation of the A&amp;G Team at Internal and External meetings/ workgroups and acts as the point person for A&amp;G Programs especially the Clinical Programs.Develop and execute on strategic opportunities to improve the overall appeals &amp; grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals.Work cross functionally and collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization.&nbsp;<h4>Duties Continued</h4>Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships. Identify areas of connection to leverage and create added value for L.A. Care.Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes. &nbsp;Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management. &nbsp;Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department. &nbsp;Develop and implement short and long-term strategies to improve team results, reducing administrative expenses.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. Supervision of the Clinical Services unit and general operations within Appeals and Grievances. Maintain a team of top talent, providing a culture of teamwork and collaboration.&nbsp;Perform other duties as assigned<h4>Education Required</h4>Bachelor's Degree in Nursing<h4>Education Preferred</h4><h4>Experience</h4>Required:6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment and/or public services or public benefits programs.At least 3 years of management level operations leadership experience.Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulationsExperience building relationships with organizations and business partners.Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.Preferred:&nbsp; Managed care experience.<h4>Skills</h4>Required: Excellent analytical, problem solving, planning and implementation skills.Demonstrated strong writing and communication skills.Demonstrates excellent leadership, communication, and negotiation skills with the ability to interact and influence all levels of the organization including executive management and key decision -makers.Demonstrates professional judgement, and critical thinking, to promote the delivery of quality, cost-effective care.Time management and priority setting skills.Excellent understanding of NCQA, DMHC, DOI, DHCS, and CMS regulatory requirements.Knowledge of Coordination of Care, Medicare and Medi-Cal regulations, prior authorization, level of care and length of stay criteria sets.Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.Able to operate PC-based software programs including proficiency in Word, Excel and PowerPoint presentations.Excellent verbal, written communication and presentation skills.<h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4>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.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 assignedSalary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.L.A. Care offers&nbsp;a wide range of benefits including<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> Nearest Major Market: Los Angeles Job Segment: Nursing, Registered Nurse, Nurse Management, Medicaid, Medicare, Healthcare

L.A. Care Health Plan

Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical)

Salary Range:&nbsp;&nbsp;$102,183.00&nbsp;(Min.) -&nbsp;$132,838.00&nbsp;(Mid.) -&nbsp;$163,492.00&nbsp;(Max.)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. 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. <h4>Job Summary</h4>The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects. The position serves as a subject matter expert (SME), performing medical records reviews to include quality audits as well as validation of accuracy and completeness of all coding elements. The position is also responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development. This position trains and mentors Payment Integrity Nurse Coder, RN staff. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.<h4>Duties</h4>Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims.Serves cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects.Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance. Identifies trends and patterns with overall program and individual provider coding practices.Responsible for training and mentoring Payment Integrity Nurse Coder, RN staff.Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success.Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review.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.Performs other duties as assigned.<h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4>Required:At least 8 years of clinical RN experience.At least 3 years of experience in utilization management or clinical coding.Investigation and/or auditing experience.<h4>Skills</h4>Required:Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.Working knowledge of claims coding and medical terminology.Solid understanding of standard claims processing systems and claims data analysis.Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment.Must be collaborative and have the ability to establish credibility quickly with all levels of management across multiple functional areas and be able to present findings across all departments.Must be familiar with coordinating benefits between health plan payers.Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.<h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California LicenseCertified Professional Coder (CPC) designation by the American Academy of Professional Codersand/orCertified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.L.A. Care offers&nbsp;a wide range of benefits including<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> Nearest Major Market: Los Angeles Job Segment: Nursing, Medical Coding, Registered Nurse, Claims, Medicare, Healthcare, Insurance

Payment Integrity Nurse Coder RN III

Job Description:POSITION SUMMARYThe Enrollment Counselor position at Pacific Oaks supports all recruitment, admissions, and advising efforts at the college. Additionally, it helps with activities by handling communications, information and paper flow with prospective and admitted students. The successful candidate will be an articulate, organized, results driven, a dynamic and enthusiastic leader, and a team player.This position is located in Pasadena and reports directly to the AVP of Admissions.ESSENTIAL JOB FUNCTIONS:<ul><li>Provide excellent customer service to prospective students throughout the full admission recruitment process</li><li>Meet daily expectations for outbound dials, set campus consultations</li><li>Meet with prospective students to counsel on completing Admissions requirements, discusses academic programs, admission options, and financial aid opportunities and conducts campus tours.</li><li>Meet/exceed Admission benchmark goals</li></ul>JOB FUNCTIONS:<ul><li>Availability to work evening shifts and a rotating Saturday shift as needed</li><li>Follow up with prospects and applicants by phone and written correspondence.</li><li>Plan and coordinate on-campus Information Sessions and Open Houses for prospective students</li><li>Regularly attends the school department staff meetings</li><li>Assist new and continuing students with registration process</li><li>Follow up with admitted/current students to ensure they maintain part-time/full-time status</li><li>Liaise with corresponding departments to support the admissions team</li><li>Ensure students meet with Faculty Advisors to outline program completion plans</li><li>Track and document all communication with Inquiries, applications and students through Salesforce and Campus Vue</li></ul><ul><li>Contributes to a work environment that encourages knowledge of, respect for, and development of skills to engage with those of other cultures or backgrounds.</li></ul><ul><li>Performs other duties as assigned.</li></ul>REQUIRED KNOWLEDGE, SKILLS &amp; ABILITIES:<ul><li>Sales knowledge, skill and experience; in addition to person-to-person account management experience</li><li>Consultative approach to answering questions, addressing concerns and assisting with enrollment decisions</li><li>Highly accountable to monthly goals, performance expectations</li><li>Ability to establish rapport and build relationships with prospective students</li><li>Demonstrated ability to multi-task, organize, manage time while meeting and/or exceeding expectations and goals</li><li>Demonstrated ability to work independently and collaborative with little supervision in an fast-paced environment</li></ul>PREFERRED KNOWLEDGE, SKILLS &amp; ABILITIES:<ul><li>Keep current on CFP, HD and SOE programs information and State licensure requirements</li><li>Understanding of and experience with non-traditional student populations</li><li>Keeps current on credential program information and the schools credentialing requirements&nbsp;</li><li>Excellent written and verbal communication skills; accuracy and attention to detail</li><li>Possess professional interaction, personal networking and constituency building skills; and possess interesting, dynamic, articulate, credible and fluid group presentation skills</li><li>Ability to meet annual inquiry plans as recorded weekly</li><li>Inquiry generation and effective inquiry follow-up capability</li><li>Self-directed and highly motivated, high activity action taking recruiting students</li><li>Executing continuous high volume contact, mapping out efficient travel logistics, coordinating and conducting events, sustaining high levels of diverse activity and multi-tasking under strict deadlines</li><li>Knowledge of the education industry</li><li>Demonstrated, consistent results producer.</li><li>Enrollment, academic advising knowledge/experience</li><li>Ability to guide prospective students through the university admissions process and overcome any obstacles that may arise</li><li>Excellent written and verbal communication required</li><li>Excellent ability to speak in public and conduct presentations for large groups and one on one.</li><li>Possess a positive and enthusiastic attitude to promote a healthy work environment.</li><li>Ability to travel evenings and weekends; possess valid driver’s license</li><li>Ability to work evenings/weekends and have a flexible schedule</li><li>Self-motivated, goal-oriented, results driven</li></ul>REQUIRED EDUCATION:<ul><li>Bachelor’s degree required with minimum of 1 years' experience in college admissions, recruitment or sales preferred; OR a minimum of 5 years' history in an enrollment/admissions position in nontraditional higher education recruitment;</li></ul>PREFERRED EXPERIENCE:<ul><li>Minimum 1-2 years’ experience in college admissions, recruitment or student services preferred.</li><li>Experience working with non-traditional students</li><li>Sales Knowledge or Sales Experience</li></ul>PHYSICAL REQUIREMENTS (based on a typical week):Key:C&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Constant(over 66% of time)F&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =Frequent(34%-66% of time)O&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Occasional(1%-33% of time)<ul><li>Lifting/carrying under 10 lbs. – O</li><li>Pushing/pulling under 10 lbs. – O</li><li>Reaching outward – O</li><li>Sitting – C</li><li>Standing – O</li><li>Bending – O</li><li>Walking on normal surfaces – F</li><li>Typing/keyboarding/ten-key – C</li><li>Fine handling/grasping – O</li><li>Repetitive motion (hands) – O</li></ul>Compensation &amp; BenefitsThis opportunity is budgeted at $20.00-21.50 base compensation. Additional compensation factors may impact total compensation. To learn more about our competitive benefits and additional rewards, including generous paid time-off, medical and dental insurance coverage, life and disability insurance, retirement plan with employer contribution, multiple flexible spending accounts, tuition reimbursement, click the link below.<a href="https://www.pacificoaks.edu/about/careers-pacific-oaks/" target="_blank">https://www.pacificoaks.edu/about/careers-pacific-oaks/</a>Pacific Oaks is an Equal Opportunity Employer.Pacific Oaks participates in E-Verify and verifies identity and employment eligibility of all persons hired. The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. Pacific Oaks offers equal employment opportunities to all persons without regard to race, color, ethnicity, religion, sex, sexual orientation, national origin, age, marital status, physical or mental disability, parental status, housing status, source of income or military status, in accordance with applicable federal, state and local EEO laws.

23 Healthcare Jobs in Los Angeles, CA, USA