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<br><h4>Overview</h4><p>LMI is seeking an experienced Principal, Chief Technology Officer with focus on our Army portfolio.&nbsp;</p><p>LMI is a new breed of digital solutions provider dedicated to accelerating government impact with innovation and speed. Investing in technology and prototypes ahead of need, LMI brings commercial-grade platforms and mission-ready AI to federal agencies at commercial speed.</p><p>&nbsp;Leveraging our mission-ready technology and solutions, proven expertise in federal deployment, and strategic relationships, we enhance outcomes for the government, efficiently and effectively. With a focus on agility and collaboration, LMI serves the defense, space, healthcare, and energy sectors—helping agencies navigate complexity and outpace change. Headquartered in Tysons, Virginia, LMI is committed to delivering impactful results that strengthen missions and drive lasting value.</p><h4>Responsibilities</h4><ul><li>Lead the identification and translation of our clients digital needs for each of our core business areas</li><li>Stay educated on emerging technologies&nbsp;</li><li>Present reports on the company’s technology status, goals and or progress</li><li>Create and oversee implementation of technology solutions &amp; strategies</li><li>Align the company’s technology resources with the organization’s short- and long-term goals</li><li>Serve on the executive committee to align technology goals to other departmental and organizational objectives</li><li>Identify what technologies can be used to improve the company’s products and services</li></ul><h4>Qualifications</h4><ul><li>The ability to drive teams in complex solution development</li><li>Demonstrated expertise in building business cases, solutions, developing proposal artifacts.</li><li>Strong ability to collaborate to get things done in a matrix organization (e.g., successful collaboration across Division/Groups in current LMI structure)</li><li>Excellent verbal and written communication skill</li><li>Organization and time-management skills</li><li>Multitasking skills</li><li>Ability to manage large budgets effectively</li><li>Knowledge of latest technological advances that could benefit company</li><li>Knowledge of all functions and roles within IT</li><li>Knowledge of best information security practices</li><li>Excellent leadership skills</li><li>Demonstrated ability to meet critical deadlines&nbsp;</li><li>Demonstrated strong culture fit and values alignment with LMI.</li><li>Demonstrated leadership capability. Team player.</li><li>Minimum 6 years’ experience in the govcon/IT market.</li><li>Advanced degree preferred.</li></ul><p>Applicants selected will be subject to a government security investigation and must meet eligibility requirements for access to classified information. LMI will only consider applicants with current security clearances. Please note that only U.S. citizens are eligible for a security clearance.</p><h4><br>LMI is an Equal Opportunity Employer. LMI is committed to the fair treatment of all and to our policy of providing applicants and employees with equal employment opportunities. LMI recruits, hires, trains, and promotes people without regard to   race, color, religion, sex, sexual orientation, gender identity, national origin, pregnancy, disability, age, protected veteran status, citizenship status, genetic information, or any other characteristic protected by applicable federal, state, or local law. If you are a person with a disability needing assistance with the application process, please contact <a href="mailto:accommodations@lmi.org" target="_blank">accommodations@lmi.org</a><br>Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of school attendance or graduation. You will not be penalized for redacting or removing this information.<br><br><b>Need help finding the right job?</b><br></h4>We can recommend jobs specifically for you!Click here to get started.<br>

Chief Technology Officer, Principal (Army)

<br><h4>Overview</h4><p>LMI seeks an experienced&nbsp;Full Stack Software Engineer&nbsp;to support the U.S. Army’s&nbsp;Holistic Health &amp; Fitness (H2F)&nbsp;initiative as a member of the&nbsp;Software functional team&nbsp;within the&nbsp;H2F Program Support Team.</p><p>The Full Stack Software Engineer is responsible for designing, developing, and maintaining software components and services that support analytics, data access, and user engagement within the Holistic Health and Fitness Management System (H2FMS). This role supports application-layer development and integration, working in coordination with data, analytics, and user engagement teams to ensure software capabilities align with Government-directed requirements.&nbsp;The Full Stack Software Engineer does&nbsp;not&nbsp;own product strategy or independently define system architecture. All work is performed under Government direction and TPM coordination, with close collaboration across functional teams.</p><p>LMI is a new breed of digital solutions provider dedicated to accelerating government impact with innovation and speed. Investing in technology and prototypes ahead of need, LMI brings commercial-grade platforms and mission-ready AI to federal agencies at commercial speed.</p><p>Leveraging our mission-ready technology and solutions, proven expertise in federal deployment, and strategic relationships, we enhance outcomes for the government, efficiently and effectively. With a focus on agility and collaboration, LMI serves the defense, space, healthcare, and energy sectors—helping agencies navigate complexity and outpace change. Headquartered in Tysons, Virginia, LMI is committed to delivering impactful results that strengthen missions and drive lasting value.</p><h4>Responsibilities</h4><ul><li>Design, develop, and maintain&nbsp;frontend and backend software components&nbsp;supporting H2FMS capabilities.</li><li>Implement software features that enable data access, analytics visualization, and user engagement workflows as directed.</li><li>Follow Government-approved development standards and practices.</li><li>Integrate application components with&nbsp;<strong>data pipelines, analytics services, and AI/ML outputs</strong>&nbsp;developed by other teams.</li><li>Collaborate with data engineers, data scientists, and user engagement specialists to ensure software supports analytic and engagement requirements.</li><li>Support integration with Government-managed or vendor-managed systems as directed.</li><li>Support testing, debugging, and resolution of software defects.</li><li>Assist with performance tuning, reliability improvements, and basic security best practices.</li><li>Participate in code reviews and configuration management processes under Government direction.</li><li>Contribute to documentation of software components, interfaces, and dependencies.</li><li>Support configuration management activities in coordination with Software Configuration Technicians.</li><li>Assist in preparing technical materials or demonstrations for Government review as required.</li></ul><h4>Qualifications</h4><p><strong>Required Qualifications</strong></p><ul><li>Bachelor’s degree in Computer Science, Software Engineering, or a related field.</li><li>Demonstrated experience developing&nbsp;full stack applications, including frontend and backend components.</li><li>Familiarity with modern web application frameworks and services.</li><li>Experience integrating applications with data services or APIs.</li><li>Ability to collaborate effectively within multidisciplinary teams spanning software, data, and analytics.</li><li>Strong problem-solving and communication skills.</li><li>Ability to obtain and maintain a&nbsp;Secret security clearance.</li></ul><p><strong>Desired Qualifications</strong></p><ul><li>Experience supporting software development in analytics- or data-driven environments.</li><li>Familiarity with cloud-based application development or deployment models.</li><li>Experience working in Agile or iterative development environments.</li><li>Prior experience supporting&nbsp;DoW or federal customers.</li></ul><p><strong>Location &amp; Travel</strong></p><ul><li>Duty Location:&nbsp;This position may be performed&nbsp;remotely.</li><li>Travel:&nbsp;Limited travel to Fort Eustis, Virginia or LMI Headquarters may be required to support integration or stakeholder engagement.</li></ul><p>Target salary range: $120,000 - 210,000.  Final compensation will be determined by a variety of factors including but not limited to your skills, experience, education, and/or certifications.</p><p>#LI-SH1</p><h4><br>LMI is an Equal Opportunity Employer. LMI is committed to the fair treatment of all and to our policy of providing applicants and employees with equal employment opportunities. LMI recruits, hires, trains, and promotes people without regard to   race, color, religion, sex, sexual orientation, gender identity, national origin, pregnancy, disability, age, protected veteran status, citizenship status, genetic information, or any other characteristic protected by applicable federal, state, or local law. If you are a person with a disability needing assistance with the application process, please contact <a href="mailto:accommodations@lmi.org" target="_blank">accommodations@lmi.org</a><br>Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of school attendance or graduation. You will not be penalized for redacting or removing this information.<br><br><b>Need help finding the right job?</b><br></h4>We can recommend jobs specifically for you!Click here to get started.<br>

Full Stack Engineer - Clearance Required

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Clinical and Regulatory Operations, is responsible for leading clinical case operations, regulatory interpretation, and clinical decision stewardship across all grievance, appeal, and State Fair Hearing cases. This position ensures that clinical and non-clinical case handling meets medical necessity standards, regulatory requirements, internal policy expectations, and quality-of-care obligations across all product lines, including Medi-Cal, Medicare, Marketplace, and delegated entities.</p><p>The Senior Manager oversees clinical operations teams responsible for medical necessity reviews, clinical grievances and appeals, Quality of Care (QOC) referrals, clinician coordination, clinical documentation quality, and regulatory interpretation. The role ensures strong collaboration with Utilization Management, the UM Medical Director, physician reviewers, Compliance, Member Services, Provider Network Management, claims teams, and the Center of Quality &amp; Excellence to support compliant, timely, and high-quality case handling.</p><p>The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Oversees end-to-end clinical case handling, including clinical grievances, clinical appeals, medical necessity review coordination, and clinical case triage and ensures consistent application of evidence-based guidelines, clinical criteria, and regulatory standards in all clinical decisions. Partners with the clinical leadership to ensure clinical decision accuracy and appropriateness. Translates clinical guidelines, regulatory requirements, and service standards into operational workflows that ensure accurate, timely, and clinically sound case handling. Ensures clinical documentation is accurate, complete, defensible, and compliant with regulatory expectations.</p><p>Oversees Quality of Care (QOC) case identification, referral, coordination, and documentation ensuring timely escalation and coordination of complex or medically nuanced grievance and appeal cases.</p><p>Strengthens the clinical and regulatory integrity of Appeals &amp; Grievances (A&amp;G) operations by guiding staff in the application of medical necessity criteria, ensuring documentation quality, and providing expert regulatory interpretation. Interprets and applies Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and internal policy requirements related to grievance and appeal processes, ensuring operations maintain regulatory alignment. Serves as a subject-matter expert for regulatory interpretation, providing guidance to operational staff and leadership. Reviews, interprets, and implements regulatory updates that impact clinical or operational grievance and appeal workflows. Partners with Compliance and Legal to resolve regulatory inquiries related to clinical and operational case-handling requirements. Supports creation and revision of clinical and operational policies, SOPs, templates, letters, and decision-support tools.</p><p>Partners with cross-functional stakeholders to ensure proper handling of clinical and non-clinical cases. Coordinates cross-functional involvement in complex cases, including providers, delegates, plan partners, and medical directors. Supports operational teams in resolving regulatory or clinical issues that arise during case handling.</p><p>Oversees training and competency development for clinical operations staff, ensuring consistent understanding of medical necessity criteria, regulatory requirements, and decision-making standards. Identifies opportunities to enhance staff capability, accuracy, and regulatory alignment across clinical case-handling processes.</p><p>Oversees clinical case reporting and trend analysis, identifying patterns in clinical appeals, grievances, and QOC findings. Provides insights to leadership related to clinical drivers of grievances and appeals, opportunities for operational improvements, and service or quality risks.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.&nbsp; Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Responsible for overseeing and managing the budgets of their respective departments.</p><h4>Duties Continued</h4><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>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.&nbsp; Ensures strong clinical judgment, regulatory understanding, and documentation discipline across the team.</p><p>Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Nursing or Related Field<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory roles.</p><p>At least 5 years of experience in leading, supervising and/or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Demonstrated experience overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting.</p><p>Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations.</p><p>Experience developing and managing corrective action plans and driving sustainable remediation.</p><p>Experience collaborating with delegated entities, plan partners, or subcontracted networks.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p><strong>Preferred:</strong></p><p>Experience with analytic dashboards and visualization tools (Power BI, Tableau).</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Proven ability to lead universe submissions, mock audits, and regulatory audit responses.</p><p>Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care.</p><p>Strong analytical, problem-solving, and critical thinking skills, including ability to translate trends into corrective actions.</p><p>Ability to design, implement, and sustain standardized processes and internal control structures.</p><p>Exceptional written and verbal communication skills, including executive communication and the ability to translate trends and other findings into actionable recommendations.</p><p>Proficiency with Microsoft Office, case management systems, and reporting tools.</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and exceptional knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>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>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><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Medicare, Medicaid, Medical Research, Healthcare                                                    </p>

L.A. Care Health Plan

Senior Manager, Clinical and Regulatory Operations

<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Business Analyst III facilitates business process improvement via the methodical investigation, analysis, review and documentation of functional business specifications. This position manages the requirements development process through the elicitation, analysis, specification and verification of multiple levels of requirements from an end-to-end perspective and supports the ongoing management of the requirements. This position develops report and analysis for the department. It is responsible in communicating and coordinating with IT on a day-to-day department related efforts. The Business Analyst III manages and coordinates the implementation and/or integration of products or new features for clients including client training and provides subject matter expertise (SME) and support of the department's inbound and outbound functions. This position acts as mentor to Business Analysts I/ II.</p><h4>Duties</h4><p>Develop functional and user acceptance test plans and scenarios. Coordinate functional and user acceptance testing by executing the testing strategy, scheduling resources and tracking test performance. Perform data analysis to support evaluation of system defects or to develop requirements for new functionality; assist in various system trouble shooting and balancing and correction efforts including analysis, verification and validation of issues and fixes. Coordinate activities including on-time delivery, testing and production moves.</p><p>Collaborate with I.T. on all department &nbsp;related efforts, including submission of Service Requests and writing BRD's. Coordinate related data requests from internal departments, and/or assist I.T. with definition of criteria. Delegate data and reporting requests to business analysts. Facilitate collaborative system and data design sessions with the user community, technical architecture resources and development resources. Preparation of status updates to enterprise for distribution and communication.</p><p>Work as a technical support and liaison to designated I.T. personnel to provide testing, support and feedback on enhancement requests and regular updates/releases; adhere to release schedules. Provide analytical support for critical corporate initiatives including business function support for system migrations and consolidations, significant business area process improvement projects and complex product installations.</p><p>Demonstrate a high level of subject matter expertise in functional area to bridge business requirements and I.T. solutions; provide technical direction and ensure compliance with best practice solutions. Practice knowledge transfer and foster change management as the organization changes and new skills are required, focusing on team/individual development to be a valued contributor.</p><p>Participate and contribute on the development/ creation of data models and interface design specifications. Support internal/ external stakeholder's roadmap and audits as needed.</p><p><br>Oversee the business process support across multiple client engagements. Communication with internal/ external stakeholders for department's submission requirements. Review submission of data against established benchmarks and coordinate correction and improvement efforts. Monitor timely and accurate outbound data submission to state and federal recipients.</p><h4>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</h4><h4>Perform other duties as assigned.</h4><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b></p><p>At least 5 years of successful experience in a quantitative role as a Business Analyst, Data Analyst, Programming Analyst, Claims processing, encounter processing.</p><h4>Skills</h4><p><strong>Required:</strong><br>Competent to work at the highest technical level of most phases of systems analysis.</p><p>Excellent verbal and written communication skills.</p><p>Coaching, Mentoring and Teaching skills.</p><p>Teamwork-focused/collaborative work style.</p><p>Demonstrated ability to work successfully on large projects.</p><p>Problem solving skills evidenced by demonstrated results in past positions.</p><p>Ability to work under tight deadlines and handle multiple/detail-oriented tasks.</p><p>Ability to influence at all levels of the organization.</p><p>Proficient in Microsoft Office and Vizio.</p><p><strong>Preferred:</strong><br>Ability to work on other programs such as SharePoint and/ or OneNote</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Department Specifics:</b></p><p><b>Customer Solution Center Appeals and Grievances:</b></p><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Business Analyst, Claims, Finance, Insurance                                                    </p>

Business Analyst III

<p><b>Salary Range:&nbsp;</b>&nbsp;$55,245.00&nbsp;(Min.) -&nbsp;$69,045.00&nbsp;(Mid.) -&nbsp;$82,867.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Lead Service Liaison position is responsible for supporting daily management functions of the outreach team, helping ensure productivity, quality, and performance targets are met.</p><p>This position serves as the subject matter expert for the execution of member and provider outreach efforts for all lines of business. This position leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.</p><h4>Duties</h4><p>Monitors and facilitates timely contact of members regarding all outreach and retention programs for all lines of business. Provides recommendations for process improvements. Monitors real-time activity and campaign management, as needed. Ensures system of record is functional to provide complete, accurate information. (50%)</p><p>Assists management in ensuring staff provides accurate, timely and quality service to our members and providers, ensuring adherence to all departmental policies, procedures, and standards. Assists with special projects and campaigns that can provide feedback for membership satisfaction. Assists with campaign management functions for outreach efforts across all lines of business. (20%)</p><p>Assists management in providing accurate and timely reports to senior leadership. Performs Quality Assurance functions for vendor outbound campaigns. Interfaces and collaborates with management and stakeholders within and outside of the organization to address and resolve questions, elevate areas of member dissatisfaction, and barriers to care. Assists with identifying and implementing related process and system improvements. (20%)</p><h4>Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Assist management in the oversight of the daily office workflow, recommends enhancements to process and procedures.</h4><h4>Guide the assigned staff in ensuring that the team's work is completed effectively. May assist in the assigning tasks and communicating project goals. Participates in team problem-solving, decision-making, and conflict resolution.</h4><h4>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</h4><h4>Performs other duties as assigned. (10%)</h4><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 2 years of customer service experience in a contact center environment, preferably in a managed care plan setting.</p><p>At least 3 months of experience leading a process, program, and/or staff.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong coaching and motivational skills.</p><p>Proficiency with Customer Relationship Management (CRM) systems and dialing platforms.</p><p>Ability to analyze data and make performance-driven recommendations.</p><p>Proficiency in Microsoft Office suite.</p><p>Ability to communication, conflict resolution, and motivational skills.</p><p>Ability to collaborate closely with a team in a collaborative and interactive environment.</p><p>Skilled in fostering teamwork and collaboration.</p><p>Ability to adjust to changing circumstances within the team.</p><p>Good verbal and written communication skills.</p><p><strong>Preferred:</strong></p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese&nbsp;&nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Relationship Manager, Customer Service                                                    </p>

Lead Service Liaison

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Electronic Data Interchange (EDI) &amp; Data Operations is responsible for leading and optimizing the day-to-day operational, analytical, and technical functions that support electronic data exchange, authorization data ingestion, accumulator management, and Explanation of Benefits (EOB) processing for L.A. Care. This includes operational oversight of all Health Insurance Portability and Accountability Act (HIPAA) standard and proprietary EDI transactions, delegated and internal authorization data loads, accumulator workflows, and the operational components of EOB generation and remediation.</p><p>The Senior Manager oversees a team who manage file intake, data validation, routing, reconciliation, testing, and issue resolution across the enterprise. This position ensures that all electronic and paper-to-electronic data supporting claims and administrative operations is accurate, timely, and compliant with regulatory, contractual, and quality expectations.</p><p>This position plays a critical leadership role in enhancing upstream controls, reducing rework, improving automation, supporting system changes, and driving continuous improvement in data operations.</p><p>Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Strengthens the reliability, accuracy, and efficiency of all electronic data processes that support claims operations, ensuring data flows through systems as intended, issues are rapidly identified and remediated, and upstream controls are continuously enhanced. Helps drive predictable outcomes, improve payment accuracy, and maintain regulatory readiness across the data ecosystem.</p><p>Manages end-to-end operational oversight of all inbound and outbound HIPAA-standard and proprietary EDI transactions (837, 835, 270/271, 276/277, 834, 278). Ensures timely, accurate, and compliant processing of electronic claims, encounters, eligibility updates, and related administrative data.</p><p>Oversees transaction monitoring, exceptions, error queues, and data rejects; ensures prompt triage and resolution. Provides oversight of requirements documentation, including business and functional requirements (BRDs/FRDs), workflow mapping, and data specifications that support operational effectiveness.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.&nbsp;</p><p>Leads oversight of delegated Electronic Load of Delegated Authorizations (ELDA) and internal clinical authorization data loads into QNXT. Ensures authorization data is timely, complete, reconciled, and supportive of accurate claims adjudication.</p><p>Monitors authorization load success rates and partners with upstream teams to resolve recurring issues. Guides enhancements that reduce manual lookup burden for claims and increase automation.</p><p>Manages operational components of the Member Out-of-Pocket (MOOP) accumulator workflow, including reconciliation, error correction, escalation management, and member remediation.</p><p>Ensures accumulator data is accurate across intake systems, accumulator databases, QNXT, and output files.</p><p>Provides reporting and trending on accumulator performance, error patterns, and upstream causes.</p><p>Shares responsibility with the Director, EDI for operational oversight of EOB generation, validation, and data flow.</p><p>Ensures EOB output files reflect accurate benefit application, share of cost, accumulation, claim decisions, and meets regulatory requirements. Troubleshoots and resolves EOB-related issues, including cost-share miscalculations, missing data, formatting discrepancies, and system defects. Supports testing of EOB templates, logic updates, and system enhancements that impact EOB accuracy and delivery.</p><p>Leads complex root cause analyses for issues impacting claims data, authorizations, accumulators, or EOBs.</p><h4>Duties Continued</h4><p>Coordinates remediation efforts with cross-functional departments. 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>Ensures corrective actions are documented, validated, and monitored to prevent recurrence. Identifies systemic issues and recommends upstream solutions to strengthen operational controls and improve accuracy.</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. Leads process and workflow redesign efforts to increase automation, reduce manual work, and improve overall data quality.</p><p>Oversees User Acceptance Testing (UAT) planning, test case creation, execution, and validation for system changes affecting EDI, authorization data, accumulators, and EOBs.</p><p>Ensures strong quality gates are consistently applied before production releases.</p><p>Works closely with the Director, EDI to prioritize enhancements and support operational readiness for system changes.</p><p>Serves as an operational liaison to cross-functional departments and delegated entities.</p><p>Communicates system availability, planned changes, incident statuses, and file processing updates clearly and consistently.</p><p>Supports internal and external partners with non-standard data requests, testing analysis, and troubleshooting.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments.</p><p>Maintains a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, and continuous operational improvement.</p><p>Perform other duties as assigned.&nbsp;</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working with healthcare data, EDI transactions, claims data operations, or managed-care administrative systems.</p><p>At least 5years of experience in leading, supervising and/or managing staff.</p><p>Experience with system integrations, data migrations, or large-scale technical implementations.</p><p>Demonstrated experience leading complex issue resolution and root cause analysis efforts.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups</p><p><strong>Preferred:</strong></p><p>Experience developing test cases, leading UAT, or supporting system configuration changes.</p><p>Experience with commercial health plan operations or delegated partner management.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong knowledge of HIPAA-standard EDI transactions and healthcare data structures.</p><p>Knowledge of MOOP accumulators, authorization workflows, and EOB data flows.</p><p>Familiarity with claims adjudication rules, cost-share logic, and benefit application.</p><p>Proficiency in SQL, Access, Excel, and related reporting or analysis tools.</p><p>Ability to interpret and produce BRDs, FRDs, process flows, and technical documentation.</p><p>Strong analytical, problem-solving, and system-thinking 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>Excellent 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>Ability to develop and manage budgets, forecast future financial outcomes, and make informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Excellent 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 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>Working knowledge of relational databases, system interfaces, or data transformation logic.</p><p>Experience with delegated entity data submissions or clearinghouse integrations.</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, Insurance                                                    </p>

Senior Manager, Electronic Data Interchange and Claims Data Operations

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Payment Integrity (PI) Operations, manages and leads critical components of L.A. Care’s enterprise Payment Integrity program, overseeing the design, execution, and continuous refinement of pre-payment and post-payment accuracy activities. This position integrates operational management with analytic, regulatory, and contract-driven development to prevent inappropriate payments, strengthen upstream controls, and ensure accurate financial outcomes across all lines of business.</p><p>The Senior Manager manages multi-functional teams responsible for prospective edit development, clinical and non-clinical pre-payment reviews, retrospective audits, overpayment/underpayment identification, recovery operations, and pipeline management. This position ensures PI programs are executed consistently, documented clearly, and aligned with regulatory, contractual, and financial expectations.</p><p>The Senior Manager works closely with cross-functional stakeholders to translate insights into actionable system changes and preventive modifications. The Senior Manager serves as the operational driver for Payment Integrity interventions, ensuring programs scale effectively, are audit-ready, and deliver measurable reductions in inaccurate or wasteful spend.</p><p>Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Leads daily operations of pre-pay and post-pay PI activities, ensuring accuracy, timeliness, and effective case management. Oversees prospective review programs including clinical editing, code auditing, algorithm-driven controls, and provider contract/benefit interpretation. Ensures post-pay functions, including data mining, recovery validation, provider outreach, and reconciliation, are accurate, transparent, and compliant. Establishes standardized workflows, documentation, and quality review expectations across all PI teams. Ensures Payment Integrity operates as a disciplined, analytically driven, and preventive control function.</p><p>Strengthens the reliability of claims processing, increases automation and cost avoidance, manages complex PI workflows, and translates regulatory and contract-driven requirements into systematic, sustainable accuracy improvements.</p><p>Oversees development, refinement, and implementation of new edits, rules, and clinical/non-clinical logic that reduce future payment errors. Translates regulatory updates, provider contract terms, benefit changes, and emerging industry standards into edit or algorithm recommendations. Manages the PI pipeline of prospective initiatives, ensuring strong prioritization, impact modeling, and timely deployment. Partners with key stakeholders to implement upstream corrections and reduce recurring defects. Ensures prospective controls improve auto-adjudication, accuracy, and reduction of rework.</p><p>Oversees identification and validation of overpayments and underpayments from solicited/unsolicited sources, analytics, and vendor partners. Ensures recoveries follow compliant workflows, including provider notification, appeal support, repayment management, and financial reconciliation. Ensures post-pay insights translate into upstream corrective actions, edit changes, or preventive improvements. Oversees development of operational processes that strengthen coordination between internal recovery teams and external vendors.</p><p>Directs analytic and data mining efforts to detect billing anomalies, emerging risk patterns, and high-impact cost avoidance opportunities. Partners with enterprise analytics to refine predictive modeling, trending dashboards, and reporting frameworks. Ensures analytical findings convert into operational interventions, policy updates, or system changes. Identifies high-risk providers, services, or claims behaviors requiring new controls or deeper review.</p><h4>Duties Continued</h4><p>Ensures PI programs align with federal, state, and contractual requirements for all lines of business. Interprets regulatory updates and directs teams to integrate changes into rules, workflows, and edit development. Ensures that benefit structures, contract terms, and pricing methodologies are correctly reflected in both pre- and post-pay activities. Partners with Compliance and SIU on cases requiring heightened review or escalated investigation.</p><p>Oversees operational execution of vendor-driven PI programs, ensuring strong Service level agreement (SLA) performance, validated results, and accurate financial reporting. Supports vendor onboarding, implementation, testing, and algorithm or rule customizations. Ensures internal teams coordinate effectively with external partners across pre-pay and post-pay programs.</p><p>Partners with cross-functional key stakeholders to resolve system issues and strengthen upstream accuracy. Serves as an advisor to internal partners on PI trends, risk areas, provider behavior insights, and recommended control changes. Ensures PI findings are shared proactively and used to influence broader operational and configuration improvements.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.&nbsp; Responsible for scheduling, training, performance, corrective actions, mentoring, 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 problem-solving skills across the team.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Responsible for overseeing and managing the budgets of their respective departments.</p><p>Manages 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.</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:&nbsp; </strong></p><p>At least 6 years of Payment Integrity, Program Integrity, medical cost containment, Fraud Waste and Abuse (FWA), data mining, claim accuracy, or related experience.</p><p>At least 5 years of experience in leading staff, Supervising and/or managing staff.</p><p>Experience leading teams, projects, initiatives, and cross-functional groups.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience in pre-pay and/or post-pay review, edit development, recovery operations, or claim logic development.</p><p>Experience interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Experience handling complex claim review, root-cause evaluation, and adhering to regulatory TAT requirements</p><p>Experience working with COB and Third-Party Liability (TPL) claims in a managed care setting.</p><p>Experience with vendor-managed PI programs.</p><p><strong>Preferred:</strong></p><p>Experience applying predictive analytics or algorithm-based PI solutions.</p><p>Experience with SQL, BI tools, or data mining platforms.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of adjudication, coding, and the application of Division of Financial Responsibility (DOFR) to claims processing.</p><p>Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.</p><p>Understanding of benefit interpretation, contract terms, and payment rules.</p><p>Strong analytical, investigative, financial, and operational skills.</p><p>Exceptional written and verbal communication skills, including executive communication and the ability to translate technical findings into actionable recommendations.</p><p>Advanced project leadership, workflow management, and prioritization skills.</p><p>Ability to collaborate with internal and external stakeholders at all levels.</p><p>Proven problem-solving skills and ability to translate knowledge to the department.</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 SIU/FWA methodologies and risk indicators.</p><p>Experience with SQL, BI tools, or data mining platforms.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC) designation by the American Academy of Professional Coders<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>

Senior Manager, Payment Integrity Operations

<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;$60,778.00&nbsp;(Min.) -&nbsp;$75,950.00&nbsp;(Mid.) -&nbsp;$91,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Category Specialist II supports the execution of L.A. Care’s category management strategies by conducting spend analysis, preparing reports, and assisting in sourcing events across assigned categories. This position partners with stakeholders to track savings, review contracts and invoices for compliance, and maintain accurate vendor and spend data within procurement systems. The Specialist ensures policy compliance and provides the foundational insights needed for sourcing execution and category strategy.</p><h4>Duties</h4><p>Support category management activities by conducting spend analysis, supplier research, and market benchmarking to identify savings opportunities and rationalize vendors. (25%)</p><p>Develop and maintain detailed reports on spend and vendor performance, contract expirations, and cost savings by using source-to-pay systems and advanced Excel/Business Intelligence (BI) tools. (15%)</p><p>Assist in sourcing execution by preparing Request for x (RFx) documentation, consolidating supplier responses, conducting cost/price comparisons, and supporting contract negotiations. (20%)</p><p>Partner with internal stakeholders to collect requirements, track supplier performance, and ensure accurate application of purchase orders, invoices, and contracts. (10%)</p><p>Ensure compliance with procurement policies and procedures by supporting contract review, validation of supplier terms, and accurate application of Accounts Payable (A/P) documentation. (5%)</p><p>Contribute to strategic initiatives including vendor rationalization projects, supplier onboarding, and process automation within source-to-pay platforms. (10%)</p><p>Provide project and administrative support for sourcing events, supplier scorecards, and quarterly business reviews. (5%)</p><p>Perform other duties as assigned, including supporting special projects and process improvement initiatives. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate'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 2 years of experience in procurement, strategic sourcing, purchasing or contract management, analyzing data in a financial and legal context.</p><p>Ariba or similar experience with strong understanding of master data management.</p><p>Experience utilizing leading-edge analytics and research tools and technologies.</p><p><strong>Preferred:</strong></p><p>Experience in managing initial and ongoing Vendor Risk elements, including cyber.</p><p>Experience negotiating and managing supplier agreements for a wide variety of goods and services.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Familiar with procurement and sourcing concepts, practices, systems and procedures.</p><p>Quick and reliable learner with extreme attention to detail.</p><p>Highly organized multi-tasker with ability to independently spot issues and work through problems with minimal to no assistance.</p><p>Excellent verbal, written communication, analytical, organizational and presentation skills.&nbsp;</p><p>&nbsp;Familiarity with healthcare and legal terminology and methodology.</p><p>Ability to prepare amendments, contracts and basic legal documents from templates.</p><p>Proficient in Microsoft PowerPoint, Excel and Office.</p><p>Strong procurement skills to support vendor relationship management.</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, Administrative Assistant, Relationship Manager, Finance, Administrative, Customer Service                                                    </p>

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