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<p><b>Salary Range:&nbsp;</b>&nbsp;$102,183.00&nbsp;(Min.) -&nbsp;$132,838.00&nbsp;(Mid.) -&nbsp;$163,492.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Manager, 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>

L.A. Care Health Plan

Manager, Claims Quality Assurance

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

Manager, Claims Compliance

<p><b>Salary Range:&nbsp;</b>&nbsp;$60,778.00&nbsp;(Min.) -&nbsp;$75,950.00&nbsp;(Mid.) -&nbsp;$91,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Workforce Management (WFM) Analyst II supports the operations by forecasting workload, planning staffing, creating schedules, and monitoring real-time performance of contact center and back-office production queues to ensure service level goals are met. This position uses data analysis, workforce tools, and cross-team collaboration to optimize resource allocation and enhance customer experience.</p><h4>Duties</h4><p>Analyzes historical workload data to develop short-, mid-, and long-term volume forecasts. Builds staffing models to identify required headcount based on service levels and department specific targets. Tracks forecast accuracy and recommends adjustments to improve planning precision.</p><p>Creates schedules aligned with forecasted volumes. Manages schedule changes, shift bids, rotations, Personal Time Off (PTO) allocations, and offline scheduled activities. Ensures optimal staffing coverage to balance service quality and cost efficiency.</p><p>Monitors real-time workload queue performance and staffing levels. Recommends and executes intraday actions to maintain service targets. Communicates operational impacts and escalations to department leadership.</p><p>Prepares daily/weekly/monthly productivity and performance reports. Identifies trends and provides analysis to support process improvements and operational decisions. Conducts root-cause analysis for service level misses or staffing issues.</p><p>Maintains WFM systems, ensuring accurate configuration and data integrity. Improves workflows through automation, reporting enhancements, and best practices. Supports new initiatives, product launches, and volume-impacting changes with data-driven insights.</p><p>Supports skilling activities to respond to real-time workload queue conditions.</p><p>Uses established guidelines, process exception requests as submitted by contact center agents and supervisors within the assigned timelines. Processes exceptions to schedules to support training, coaching and meeting requests while ensuring that there is adequate coverage for all contact center channels.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 2 years of workforce management experience in a contact center environment.</p><p>Extensive experience with forecasting and scheduling activities.</p><p>Demonstrated experience finding multiple solutions to complex problems.</p><p>Strong experience and understanding of staffing, work queues, and performance measurements.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Knowledge of WFM tools.Ability to interpret WFM data to assist with determining staffing needs.</p><p>Strong analytical and problem-solving skills.</p><p>Strong attention to detail and accuracy skills.</p><p>Ability to learn new systems quickly with minimal support.</p><p>Proficient skills in Excel (formulas and pivot tables).</p><p>Proven ability to meet goals and deadlines.</p><p>Ability to manage multiple priorities and tasks in a fast-paced environment.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    HR, Human Resources                                                    </p>

Workforce Management Analyst II

<p><b>Salary Range:&nbsp;</b>&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Customer Engagement and Experience Member Advocate III serves as a high-level resource and member support specialist within L.A. Care’s Customer Engagement and Experience operations. This position advocates and assists members in navigating their health plan benefits, accessing care, resolving issues, addressing waste and abuse, and connecting to community, clinical, and social services.</p><p>The Customer Engagement and Experience Member Advocate III handles complex, sensitive, or escalated cases. Provides guidance to other advocates. &nbsp;Collaborates across departments to improve the member experience. This position plays a key role in supporting retention, satisfaction, and access to care for our underserved population. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Assists members with complex benefit questions, care navigation challenges, grievances, access to services, and issue resolution. Conducts high-touch outreach to support vulnerable or high-risk populations, including seniors, individuals with chronic conditions, and members with unmet social needs. Serves as a subject matter expert for benefit interpretation, care coordination pathways, and service workflows. Resolves escalated inquiries from customer service, care management, and provider relations.</p><p>Helps members understand coverage, Primary Care Physician (PCP) selection, referrals, authorizations, and healthcare system processes. Connects members to community resources related to housing, food, transportation, financial assistance, behavioral health, and other social determinants of health (SDoH) needs. Coordinates with cross-functional key stakeholders to remove barriers to care.</p><p>Supports member engagement initiatives such as health literacy outreach, preventive care reminders, redetermination support, and quality-improvement campaigns (e.g., Healthcare Effectiveness Data and Information Set (HEDIS), California Association of Health Plans (CAHPS)). Participates in member experience programs focused on improving satisfaction, retention, and service outcomes. Documents member feedback and identifies recurring pain points for operational improvement.</p><p>Works closely with cross-functional key stakeholders to address member needs. Assists with complex cases requiring multi-department coordination. Serves as a representative for Member Advocacy on workgroups or improvement projects.</p><p>Accurately documents all member interactions, interventions, and referrals in the plan’s systems. Escalates potential quality-of-care issues, safety concerns, or compliance risks to appropriate teams. Maintains confidentiality in accordance with Health Insurance Portability and Accountability Act (HIPAA) and managed care regulations. Supports audit readiness through timely, accurate, and complete documentation.</p><p>Apply subject matter expertise in evaluating business operations and processes. Identify areas where technical solutions would improve business performance. Consult across business operations, provide mentorship, and contribute specialized knowledge. Ensure that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provide training and recommend process improvements as needed.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree in Healthcare or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience in member services, advocacy, care coordination, customer service, or healthcare navigation.</p><p>Experience working with vulnerable, underserved, and culturally diverse populations.</p><p>Experience resolving individual cases with regulatory state agencies.</p><p><strong>Preferred:</strong></p><p>Experience in Medicaid, Medicare, or managed care environments strongly preferred.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of health plan benefits, medical terminology, and the healthcare delivery system.</p><p>Excellent communication, problem-solving, and conflict-resolution skills.</p><p><strong>Preferred:</strong></p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.&nbsp;&nbsp;</p><p>Ability to handle sensitive and complex member issues with compassion and professionalism.</p><p>Knowledge of community and social service resources.</p><p>Proficiency with CRM systems, case management tools, and documentation standards.</p><p>Strong organizational skills and ability to manage multiple priorities.</p><p>Knowledge of healthcare regulations and policies and procedures.</p><p>Excellent public speaking/public presentation skills.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicaid, Medicare, Behavioral Health, Social Services, Healthcare, Service                                                    </p>

Customer Engagement and Experience Member Advocate III

<p><b>Salary Range:&nbsp;</b>&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Customer Engagement and Experience Member Advocate III serves as a high-level resource and member support specialist within L.A. Care’s Customer Engagement and Experience operations. This position advocates and assists members in navigating their health plan benefits, accessing care, resolving issues, addressing waste and abuse, and connecting to community, clinical, and social services.</p><p>The Customer Engagement and Experience Member Advocate III handles complex, sensitive, or escalated cases. Provides guidance to other advocates. &nbsp;Collaborates across departments to improve the member experience. This position plays a key role in supporting retention, satisfaction, and access to care for our underserved population. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Assists members with complex benefit questions, care navigation challenges, grievances, access to services, and issue resolution. Conducts high-touch outreach to support vulnerable or high-risk populations, including seniors, individuals with chronic conditions, and members with unmet social needs. Serves as a subject matter expert for benefit interpretation, care coordination pathways, and service workflows. Resolves escalated inquiries from customer service, care management, and provider relations.</p><p>Helps members understand coverage, Primary Care Physician (PCP) selection, referrals, authorizations, and healthcare system processes. Connects members to community resources related to housing, food, transportation, financial assistance, behavioral health, and other social determinants of health (SDoH) needs. Coordinates with cross-functional key stakeholders to remove barriers to care.</p><p>Supports member engagement initiatives such as health literacy outreach, preventive care reminders, redetermination support, and quality-improvement campaigns (e.g., Healthcare Effectiveness Data and Information Set (HEDIS), California Association of Health Plans (CAHPS)). Participates in member experience programs focused on improving satisfaction, retention, and service outcomes. Documents member feedback and identifies recurring pain points for operational improvement.</p><p>Works closely with cross-functional key stakeholders to address member needs. Assists with complex cases requiring multi-department coordination. Serves as a representative for Member Advocacy on workgroups or improvement projects.</p><p>Accurately documents all member interactions, interventions, and referrals in the plan’s systems. Escalates potential quality-of-care issues, safety concerns, or compliance risks to appropriate teams. Maintains confidentiality in accordance with Health Insurance Portability and Accountability Act (HIPAA) and managed care regulations. Supports audit readiness through timely, accurate, and complete documentation.</p><p>Apply subject matter expertise in evaluating business operations and processes. Identify areas where technical solutions would improve business performance. Consult across business operations, provide mentorship, and contribute specialized knowledge. Ensure that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provide training and recommend process improvements as needed.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree in Healthcare or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 5 years of experience in member services, advocacy, care coordination, customer service, or healthcare navigation.</p><p>Experience working with vulnerable, underserved, and culturally diverse populations.</p><p>Experience resolving individual cases with regulatory state agencies.</p><p><strong>Preferred:</strong></p><p>Experience in Medicaid, Medicare, or managed care environments strongly preferred.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of health plan benefits, medical terminology, and the healthcare delivery system.</p><p>Excellent communication, problem-solving, and conflict-resolution skills.</p><p><strong>Preferred:</strong></p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.&nbsp;&nbsp;</p><p>Ability to handle sensitive and complex member issues with compassion and professionalism.</p><p>Knowledge of community and social service resources.</p><p>Proficiency with CRM systems, case management tools, and documentation standards.</p><p>Strong organizational skills and ability to manage multiple priorities.</p><p>Knowledge of healthcare regulations and policies and procedures.</p><p>Excellent public speaking/public presentation skills.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Behavioral Health, Social Services, Medicaid, Medicare, Healthcare, Service                                                    </p>

<p><b>Salary Range:&nbsp;</b>&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Customer Engagement and Experience (CE&amp;E) Project Manager II manages, assesses and executes strategies based on identified stakeholder needs, as well as regulatory requirements. The position is responsible for overseeing the department's outreach and engagement projects aligned with organizational strategic goals and department initiatives. The position will work closely and aid each CE&amp;E vertical by creating project documentation and workflows, managing interdepartmental traffic/requests for CE&amp;E department project support, maintaining vertical SharePoint sites, and developing and maintaining a master calendar of CE&amp;E projects, activities and regulatory timeframes. The position will participate in the development, monitoring, and up keep of all Desk Level Procedures and Policies and Procedures, ensuring an annual review is implemented and completed. Works closely with the CE&amp;E Technical Writer to ensure processes and procedures are accurately configured in the On Line Help Tool and assist the CE&amp;E Program and Initiatives Managers with project execution and implementation.</p><h4>Duties</h4><p>Partners, supports and collaborates with key stakeholders in scoping, implementing, evaluating and managing portfolio of assigned projects.&nbsp; Oversees the development and strategic implementation of multimodal member communications programs for all Line of Business (LOBs), including product/service-specific campaigns across multiple distribution channels.</p><p>Collaborates with and leads cross-functional project teams to address project requirements, including developing/tracking deliverables and maintaining regular on going communication with project stakeholders; develop and maintain Desk Level Procedures/Policies and Procedures. Maintain knowledge of product line contracts, regulations, requirements, and obligations and ensure responsible business units are compliant with requirements.</p><p>Identifies, recommends and applies business solutions derived from research and analysis findings for all assigned CE&amp;E projects/programs. Documents project/program and business workflows and processes, project plans and meeting minutes with input from key stakeholders and project team members. Lead process evaluation and improvement activities and analysis and research activities in areas such as customer satisfaction and best practices.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business Administration or Healthcare AdministrationIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><strong>Required:</strong></p><p>At least 3 years of experience in project management with the demonstrated experience on the following list of stated knowledge, experience and/ or skills.</p><p>Experience in developing work plans/documents, working in databases.</p><p><strong>Preferred:&nbsp; </strong></p><p>Previous experience in project/program management with health plan or provider services/operations and knowledge of Medicaid managed care.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong interpersonal, written and verbal communication skills, and work collaboratively and independently within the established guidelines, policies, and procedures.</p><p>Detailed oriented and excellent organizational skills.&nbsp;</p><p>Proficiency in Microsoft Office applications and Visio.</p><p>Facilitation of discussions regarding member communication processes.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Project Management Professional (PMP)<h4>Required Training</h4><h4>Physical Requirements</h4><h4>Additional Information</h4><p>Required:</p><p>Bachelors Degree in Business Administration, Healthcare Administration, or Public Health.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Healthcare Administration, Medicaid, Public Health, Healthcare                                                    </p>

Customer Engagement and Experience Project Manager II

<p><b>Salary Range:&nbsp;</b>&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Director, Payment Integrity defines the payment integrity operating model.&nbsp; As owner, is accountable for prevention, governance, analytics, risk reduction and sustained accuracy across all prepay and post pay activity.&nbsp; This position is responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program. This position ensures the accuracy of provider payments, minimized inappropriate spend, and strengthens preventive and detective controls across all lines of business. The Director oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, coordination of benefits (COB), third-party liability (TPL), and analytical review of billing and payment patterns.</p><p>The Director sustains a Payment Integrity operating model that prevents incorrect payments before they occur, improves the reliability of claims processing through strong upstream controls, identifies systemic issues contributing to payment errors, and drives operational, configuration, or provider-facing changes that improve accuracy over time. This leader partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.</p><p>The Director leads a multi-functional team that includes internal data mining, clinical review, overpayment recovery, prospective pre-payment programs, and vendor management. The Director is responsible for building analytic and operational rigor, embedding standardized processes, and fostering a culture of accountability, operational consistency, and continuous improvement.</p><p>This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Develops strategic plans, drives change and influences critical business outcomes.</p><h4>Duties</h4><p>Strengthens accuracy, prevents financial leakage, and ensures upstream and downstream controls operate as a cohesive system. Refines and enhances disciplined processes, improves the sustainability of controls, and leverages data to identify and mitigate risks before they impact members, providers, or financial performance. Through cross-functional collaboration, structured execution, and proactive problem-solving, enhances the organization’s ability to manage medical spend responsibly and ensure accurate, compliant payment outcomes.</p><p>Develops and executes the Payment Integrity strategy, ensuring alignment with enterprise financial, operational, and regulatory priorities. Leads a comprehensive operating model that integrates pre-pay, post-pay, clinical editing, cost-avoidance, data mining, recovery operations, COB, and TPL functions.&nbsp; Designs and maintains governance frameworks, policies, workflows, and quality standards that strengthen preventive controls and reduce rework.&nbsp; Ensures consistent application of rules, benefit interpretation, pricing methodologies, and contract terms across all Payment Integrity activities.</p><p>Oversees the development and implementation of pre-payment controls including clinical editing, code auditing, configuration recommendations, automated and algorithm-based edits, and pre-pay clinical and non-clinical reviews. &nbsp;Partners with cross functional teams to implement upstream changes that prevent recurring payment errors and reduce operational burden.&nbsp; Leads initiatives that increase automation, improve first-pass accuracy, and reduce the volume of post-pay recoveries.</p><p>Oversees identification, validation, and recovery of overpayments across solicited and unsolicited sources, ensuring accuracy, transparency, and regulatory compliance.&nbsp; Leads recovery operations, including provider outreach, appeals support, repayment management, and reconciliation of recovery outcomes. Ensures post-pay findings feed into proactive improvements and preventive interventions, reducing future inappropriate payments.<br><br><br></p><h4>Duties Continued</h4><p>Directs internal data mining and analytical review functions to identify billing anomalies, emerging risk patterns, and cost avoidance opportunities.&nbsp; Partners with Analytics leaders to develop predictive models, dashboards, and trending tools that support smarter interventions and program scalability.&nbsp; Translates analytical insights into operational or system changes that reduce leakage and strengthen the accuracy of initial payment decisions.<br>Oversees COB and TPL programs to ensure correct payer order, maximize cost avoidance, and support regulatory reporting requirements.&nbsp; Ensures timely, accurate, and complete responses to inquiries from DHCS or other regulatory bodies.&nbsp; Strengthens processes to reduce inappropriate payments that result from eligibility, coordination, or primary payer errors.</p><p>Manages relationships with Payment Integrity vendors, ensuring contract compliance, performance against SLAs, timely implementation of new programs, and accurate financial reconciliation.&nbsp; Assesses vendor performance and identifies opportunities to optimize or expand program impact.&nbsp; Ensures vendor partners follow appropriate standards, quality controls, and documentation expectations.</p><p>Ensures Payment Integrity processes meet all regulatory and contractual requirements across Medicaid, Medicare, Commercial, and Exchange lines of business.&nbsp; Leads or supports responses to audits, inquiries, corrective action plans, and regulatory reviews related to payment accuracy.&nbsp; Partners with QA to validate accuracy and consistency of Payment Integrity findings, recoveries, and interventions.</p><p>Collaborates with Claims Administration, Configuration, Provider Network Management, EDI, Compliance, and Finance to address systemic issues and improve end-to-end payment outcomes.&nbsp; Advises leadership and internal partners on payment accuracy trends, root-cause drivers, provider impact, and mitigation strategies.&nbsp; Builds strong relationships with provider partners and communicates clearly on payment rules, system behaviors, and corrective actions.</p><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively.&nbsp;</p><p>Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.&nbsp; Identifies and actualizes enhancements to support company vision.&nbsp;</p><p>Develops and maintains relationships with key stakeholders.&nbsp; Leads discussions on policy operationalization and oversees key policy perspective sharing.</p><p>Oversees succession planning to build technical expertise and operational consistency.&nbsp; Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><h4>Perform other duties as assigned.</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 7 years of deep experience in Payment Integrity, Fraud/Waste/Abuse prevention, Claims Accuracy, Medical Cost Containment, and/or other Program Integrity functions.</p><p>At least 5 years of experience leading, supervising and/or managing staff.</p><p>Demonstrated experience in pre-pay and/or post-pay program oversight, cost-avoidance strategies, recovery operations, clinical editing, or data mining.</p><p>Experience working with and interpreting provider contracts, benefit structures, pricing methodologies, and Medicaid/Medicare regulatory requirements.</p><p><strong>Preferred:</strong></p><p>Experience developing and overseeing COB/TPL programs.</p><p><br>Experience engaging with regulators, responding to audits, and overseeing and managing vendor partners.</p><p><br>Experience implementing predictive analytics or algorithm-based Payment Integrity solutions.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.</p><p>Deep understanding of payment accuracy, claim rules, industry coding standards, reimbursement methodologies, and cost-containment strategies.</p><p>Strong analytical, financial, risk-management and problem-solving skills.</p><p>Ability to manage complex workflows, prioritize competing demands, and deliver results in high-volume environments.</p><p>Ability to build strong teams that work effectively together and collaborate across the organization</p><p>Ability to establish and maintain effective working relationships with representatives at provider organizations and with internal stakeholders.</p><p>Ability to interpret and apply complex operating instructions, state and federal regulations, and department/division procedures. Ability to understand, apply, and communicate rules, regulations and guidelines to others.</p><p>Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations.</p><p>Proficiency with Microsoft Office and data/reporting tools.</p><p>Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.</p><p>Demonstrated ability to make sound and timely decisions.</p><p>Demonstrated ability to adapt to changing situations and adjust strategies accordingly.</p><p>Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.</p><p>Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.</p><p>Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicaid, Claims, Medicare, Risk Management, Healthcare, Insurance, Finance                                                    </p>

Director, Payment Integrity

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Claims Adjustments manages all adjustment-related operational workflows, including provider disputes, escalated claim reviews, complex adjustments, and litigation-related claim support. This position ensures that adjustment decisions are accurate, timely, consistent, and fully compliant with state, federal, and contractual requirements. The position functions as the operational leader for all claim adjustments that exceed routine examiner responsibilities and require higher-level investigation or coordination.</p><p>The Senior Manager leads a team of adjustment analysts and dispute specialists, building a culture of accuracy, documentation discipline, transparency, and initiative-taking issue identification.</p><p>The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Manages daily operations for all non-routine claim adjustments, including escalated cases, complex pricing reviews, and benefit or authorization-related adjustments. Ensures that adjustments are accurate, compliant, and completed within regulatory and contractual timeframes.</p><p>Oversees consistent application of payment rules, contract terms, and standardized work instructions. Builds and maintains clear adjustment pathways based on claim type, complexity, and regulatory requirements.</p><p>Oversees provider disputes requiring adjustment, including root-cause analysis and documentation of findings.</p><p>Ensures all provider adjustments meet Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and contractual (TAT) requirements.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Provides operational support for high-profile or complex provider inquiries involving reimbursement, coding, contract terms, or medical policy.</p><p>Manages communication with cross-functional departments and/or teams when needed. Ensures all adjustments are documented accurately and consistently, supporting audit readiness.</p><p>Partners with Compliance to validate adherence to regulatory standards and internal policies. Escalates potential compliance gaps or systemic issues that may require corrective action.</p><p>Partners with Legal to support claim-level discovery, case review, and preparation of adjustment packages.</p><h4>Duties Continued</h4><p>Provides operational insight on benefit application, contract interpretation, and pricing methodology relevant to legal inquiries. Ensures adjustments completed in relation to litigation or legal review are precise and audit ready.</p><p>Collaborates closely with cross-functional departments to resolve adjustment-related dependencies. Communicates root-cause drivers of adjustment volume and advocates for upstream corrections. Ensures adjustment processes are aligned with enterprise standards and system logic.</p><p>Develops reports and dashboards tracking adjustment volume, turnaround performance, accuracy trends, and systemic issues. Identifies trends in adjustment drivers and collaborates on upstream solutions that reduce rework.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions</p><p>Provides executive summaries for high-risk or high-complexity adjustment issues.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments.</p><p>Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working in claims, provider disputes, adjustments, or related operational functions.</p><p>At least 5 years of experience in leading, supervising and/or managing staff</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience in interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Experience managing complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups</p><p><strong>Preferred: </strong></p><p>Experience supporting regulatory audits, legal reviews, or corrective action plans.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules.</p><p>An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.</p><p>Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS).</p><p>Strong analytical and decision-making skills for complex claim scenarios.</p><p>Ability to provide reporting requirements based on processes and/or regulatory requirements</p><p>Proven critical thinking skills and ability to translate knowledge to the department</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and exceptional knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Strong verbal, written communication, and presentation skills, including executive communication.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicaid, Claims, Medicare, Healthcare, Insurance                                                    </p>

Senior Manager, Claims Adjustments

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Appeals &amp; Grievance (A&amp;G) Center of Quality &amp; Excellence is a strategic leader responsible for driving operational performance, regulatory compliance, service quality, and continuous improvement across all appeals and grievance functions. This position ensures accuracy, completeness, compliance, and audit-readiness of grievance, appeal, and State Fair Hearing case files across all product lines, including Medi-Cal, Medicare, Marketplace, and commercial products. The Senior Manager manages a comprehensive quality and audit program that includes case accuracy audits, documentation integrity reviews, timeliness monitoring, regulatory audit preparation, universe submissions, corrective action management, and governance of policies and standard operating procedures.</p><p>The Senior Manager collaborates closely with a cross-functional management team to identify systemic issues, strengthen internal controls, and ensure sustainable compliance with Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements. The Senior Manager ensures the A&amp;G department maintains the highest standard of documentation quality, operational integrity, and regulatory alignment.</p><p>The Senior Manager Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Strengthens the control environment across A&amp;G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations.</p><p>Manages the A&amp;G quality assurance program, ensuring systematic audits of case accuracy, documentation completeness, decision rationale, classification accuracy, letter quality, and regulatory alignment.</p><p>Oversees validation of issue codes, categories, decisions, and disposition accuracy for grievance and appeal cases across all lines of business.</p><p>Conducts quality reviews of delegated entities and plan partners to ensure contractual and regulatory alignment, coordinating with Provider Network Management as appropriate. Ensures continuous monitoring of documentation quality and supports operational teams in remediation of identified gaps.</p><p>Administers the A&amp;G audit readiness program, ensuring the department maintains sustainable compliance with DHCS, DMHC, CMS, NCQA, and other governing agencies.</p><p>Oversees preparation for all internal, external, and regulatory audits, including universe submissions, case file reviews, evidence packet integrity, corrective action plans, and readiness assessments. Ensures case file integrity through routine audits validating completeness, accuracy, timeliness, and regulatory adherence.</p><p>Oversees timeliness monitoring and reporting, identifying trends and partnering with operational teams to implement timely corrective actions.</p><p>Leads internal mock audits and guides teams through audit-life-cycle activities, from preparation to response to sustainability.</p><p>Partners with cross-functional departments to strengthen control environments and resolve systemic issues. Strengthens the control environment across A&amp;G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations.</p><p>Identifies systemic issues, drives corrective action, supports operational improvement, and ensures A&amp;G maintains continuous compliance. Oversees the development, execution, and monitoring of corrective action plans (CAPs) associated with operational, quality, or regulatory audit findings.</p><p>Monitors CAP performance to ensure timely closure, sustainable outcomes, and ongoing compliance with regulatory expectations. Ensures cross-functional alignment and accountability for quality- and audit-related corrective actions.</p><p>Translates regulatory expectations, operational requirements, and quality standards into dependable, sustainable, and high-performing quality and audit programs. Oversees creation, annual review, and maintenance of policies, procedures, desktop guides, templates, and decision-support tools for A&amp;G activities.</p><p>Ensures compliance with evolving regulatory standards and alignment with enterprise governance and operational workflows.</p><h4>Duties Continued</h4><p>Partners with senior management to validate training effectiveness and ensure process adherence across operational teams.</p><p>Produces and oversees quality, audit, and compliance trend reporting, including timeliness metrics, accuracy outcomes, and recurring error themes.</p><p>Provides data-driven insights and actionable recommendations to A&amp;G leadership, executive leaders, and cross-functional governance committees.</p><p>Maintains quality dashboards and partners with analytics teams to strengthen visibility into operational</p><p>performance and quality indicators.</p><p>Collaborates with cross-functional management teams to resolve root-cause issues and strengthen processes.</p><p>Supports enterprise-level initiatives related to service performance, regulatory compliance, audit preparedness, and operational improvement.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/or executive management to define, prioritize, and develop projects and programs.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Responsible for overseeing and managing the budgets of their respective departments.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.&nbsp; Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Ensures workforce planning supports quality and audit program needs.</p><p>Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory positions.</p><p>At least 5 years of experience in leading, supervising and/or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience in overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting.</p><p>Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations.</p><p>Experience developing and managing corrective action plans and driving sustainable remediation.</p><p>Experience collaborating with delegated entities, plan partners, or subcontracted networks.</p><p><strong>Preferred:</strong></p><p>Experience with analytic dashboards and visualization tools (Power BI, Tableau).</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Proven ability to lead universe submissions, mock audits, and regulatory audit responses.</p><p>Strong leadership and stakeholder management skills.</p><p>Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care.</p><p>Strong analytical and critical thinking skills, including ability to translate trends into corrective actions.</p><p>Ability to design, implement, and sustain standardized processes and internal control structures.</p><p>Proficiency with Microsoft Office, case management systems, and reporting tools.</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment.</p><p>Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Exceptional verbal, written communication, and presentation skills. Includes executive communication and the ability to translate trends and other findings into actionable recommendations.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Lean Six Sigma certification (Green Belt or higher)Project Management Professional (PMP)Program Management Professional (PgMP)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicaid, Medicare, Healthcare                                                    </p>

502 Jobs in Long Beach, CA, USA