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<p><b>Salary Range:&nbsp;&nbsp;<b><b><b><b>$46,800.00</b></b></b></b>&nbsp;(Min.) -&nbsp;<b><b><b><b>$52,597.00</b></b></b></b>&nbsp;(Mid.) -&nbsp;<b><b><b><b>$62,270.00</b></b></b></b>&nbsp;(Max.)</b></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 Quality and Population Health Coordinator I (QPHC) is responsible for outreaching to members to close care gaps. The QPHC also outreaches to providers for medical record pursuit and retrieval.&nbsp; This position supports the L.A. Care medical groups by assisting with scheduling member appointments. While this role is a combination of remote and in office work, this role is intended to support L.A. Care medical groups by being embedded in the provider offices and providing direct outreach to L.A. Care members. The QPHC is an important member of L.A. Care’s quality improvement team, helping to drive improvement in health outcomes, population health, and health equity, as well as member and provider experience.</p><h4>Duties</h4><h4>Make outbound calls to members to assist with scheduling and coordinating services (e.g. appointments, lab tests, health screenings, other diagnostic studies, transportation, etc.). (25%)</h4><h4>Educate members on missing gaps in care. Encourage them to close care gaps and pursue preventative health and health promotion activities such as health fairs. (25%) </h4><h4>Outreach to providers to request medical reports by fax, electronic medical records, or on-site visits if needed. (15%) </h4><h4>Review medical records, claims, and encounter data to identify key information to help close gaps in care. (15%)</h4><h4>Provide support as needed for care gap closure campaigns and other quality improvement programs. (15%)</h4><p>Perform other duties as assigned. (5%)</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><b>Required:</b></p><p>At least 3 months of experience following basic workflows, procedures, and standards related to patient or provider communication and outreach.</p><p>Previous experience working in an office setting with basic office equipment such as telephones, fax machines, computers, etc.</p><p><b>Preferred:</b></p><p>Health Plan, provider practice, or health education experience. </p><h4>Skills</h4><p><b>Required:</b></p><p>Demonstrates deep compassion and sensitivity towards patient needs and community well-being. </p><p>Driven by strong motivation to positively impact people’s lives.</p><p>Excellent verbal and written communication skills.</p><p>Excellent interpersonal skills.</p><p>Proficient with Microsoft Word, Excel, PowerPoint, and Outlook.</p><p>Skills in utilizing various online platforms and search engines to efficiently gather accurate and relevant information. </p><p>Highly organized with ability to maintain accurate notes and records.</p><p>Demonstrates high efficiency in managing tasks and consistently delivering projects to successful and reliable completion. </p><p>Ability to communicate effectively with patients and health care providers. </p><p><b>Preferred:</b></p><p>Some knowledge of HEDIS and other quality measures.</p><p>Some knowledge of quality improvement processes.</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>Active &amp; Current Driver's License, with a clean record and Auto Insurance Required<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Required:</b></p><p>Travel to offsite locations for work.</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>This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.</p><p><br><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>                    EMR, Claims, Medical, Equity, Healthcare, Insurance, Finance                                                    </p>

L.A. Care Health Plan

Quality and Population Health Coordinator I (ALD)

<p><b>Salary Range:&nbsp;&nbsp;<b><b><b><b>$88,854.00</b></b></b></b>&nbsp;(Min.) -&nbsp;<b><b><b><b>$132,838.00</b></b></b></b>&nbsp;(Mid.) -&nbsp;<b><b><b><b>$163,492.00</b></b></b></b>&nbsp;(Max.)</b></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 Payment Integrity Nurse Coder II will learn and obtain certification in coding as well as perform medical records reviews to include quality audits, provide validation of accuracy and completeness of all coding elements. This role is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects. The position will also be responsible for participating in Payment Integrity initiatives to include concept and cost avoidance development.</p><h4>Duties</h4><p>Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims.</p><p>Serves cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects.</p><p>Learns and becomes knowledgeable in all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance. Identifies trends and patterns with overall program and individual provider coding practices.</p><p>Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success.</p><p>Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review.</p><p>Performs other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p><strong>Required:</strong><br>At least 5-7 years clinical experience and a minimum of 2 years in utilization management or clinical coding.</p><h4>Skills</h4><p><strong>Required</strong>:<br>Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.</p><p>Investigation and/or auditing experience.</p><p>Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.</p><p>Working knowledge of claims coding and medical terminology.</p><p>Solid understanding of standard claims processing systems and claims data analysis.</p><p>Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.</p><p>Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment.</p><p>Must be collaborative and have the ability to establish credibility quickly with all levels of management across multiple functional areas and be able to present findings across all departments.</p><p>Must be familiar with coordinating benefits between health plan payers.</p><p>Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC) designation by the American Academy of Professional CodersCertified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).<h4>Required Training</h4><p><strong>Required:&nbsp;</strong><br>Responsible for completing an approved certified coding course within six months of date of hire.</p><p>Responsible for completing Coding Certification of above approved course work within one year of date of hire.</p><h4>Physical Requirements</h4><h4>Additional Information</h4><p><strong>Required:</strong><br>Responsible for obtaining Certified Professional Coder (CPC) designation by the American Academy of Professional Coders.</p><p>Current Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA) within one year of date of hire.</p><p><strong>Salary Range Disclaimer:</strong> 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><br><strong>L.A. Care offers&nbsp;a wide range of benefits including</strong></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, Nursing, Registered Nurse, Claims, Medicare, Healthcare, Insurance                                                    </p>

Payment Integrity Nurse Coder RN II

<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 Health Plan Field Territory Representative II maintains professional working knowledge of L.A. Care products: Cal MediConnect, Medi-Cal, L.A. Care Covered, L.A. Care Covered Direct, and the future Duals Special Needs Plan for the express purpose of growth and retention initiatives. The position entails implementing territory-sales outreach activities such as community based marketing and events, provider outreach and engagement and other territory lead generation activities and overall lead book of business oversight. For the Medicare and Commercial lines of business, territory management/outreach and lead generation activities should be aligned to broker agents (Territory Reps can enroll as needed) in order to manage scalable and diverse territory sales resources and to leverage those agents' territory relationships and resources. This position manages their territory's lead book of business and target conversion rates including managing self-generated leads (with and without broker agents) and those provided by marketing campaigns and from the Inside Sales and Retention Team.</p><h4>Duties</h4><p><b>Provider Marketing</b></p><p>Sells our CalMediconnect plan and future Dual Eligible Special Needs Plan to Medicare beneficiaries residing in Los Angeles County. Responsible for selling our Medicare product through working with our network of physicians, hospitals, medical groups and other strategic relationships.</p><p><b>Outreach Activities and Events</b></p><p>Coordinates and conducts community presentations on program eligibility, and participates in community networking meetings, senior health care activities, health fairs and outreach events. Identifies grassroots opportunities, networking and referral generation. Develops and cultivates internal and external relationships. </p><p><b>Telesales and In-Home Appointments</b></p><p>Representatives are required to also engage in telesales activities meant to support Provider and Outreach activities. Representatives are asked to self-generate leads as well as work leads assigned to them by management with the express purpose of enrollment prospective members in our plans. In addition representatives are also asked to facilitate and coordinate in-home appointments for members requesting them.</p><p><b>Sales Data Management</b></p><p>Ensures the integrity of data. Effectively utilizes the Customer Relationship Management (CRM) system to manage the sales referral pipeline and lead algorithm assignments. Enters Data accurately by following the Goldmine and QNXT guidelines. Responsible for maintaining the quality and integrity of the CRM database through constant training on upgrades on the CRM data database. Maintains a high proficiency of the internal and external systems. Demonstrates efficient use of internal proprietary systems, including but not limited to: CISCO, QMEIS, MEIS, QNXT, PDM, MARx, Member360, and AEVS to pre-screen prospective members for all lines of business.</p><h4>Duties Continued</h4><p><b>Product Sales Regulatory Compliance:</b></p><p>Adheres to compliance of Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), and L.A. Care's Regulatory Affairs &amp; Compliance regulatory guidelines. </p><p><b>Monthly and Quarterly Product Sales Performance Goals:</b></p><p>Consistently meets the minimum organizational and departmental enrollment benchmarks for product growth campaigns and meets minimum monthly and quarterly performance and production standards for a Level II representative. Performance and production standards may be adjusted on a monthly, quarterly or annual basis as required to meet the department goals and objectives for all lines of business.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p><b>Required:</b><br>Minimum of 2 years of field sales experience.</p><p><b>Preferred:</b><br>Experience in sales of &nbsp;Managed Care products including Medicare Advantage, Medi-Cal and Covered California.</p><h4>Skills</h4><p><b>Required:</b><br>Excellent interpersonal and client interaction skills with strong attention to detail and accuracy.</p><p>Must possess excellent writing skills and calm/professional telephone presence.&nbsp;</p><p>Ability to multi-task; flexible and comfortable working in a fast paced environment and committed to meeting deadlines.&nbsp;</p><p>Great attitude, energy and enthusiasm are critical.</p><p>Proficient skills in Microsoft Word, Excel, PowerPoint and Outlook.</p><p><b>Preferred:</b><br>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>Life &amp; Health Insurance License  - Active, current and unrestricted California LicenseAmerica's Health Insurance Plan (AHIP) Medicare Designation and Covered CA Certification  (Or must be obtained within 90 days from date of hire.)<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><b>Required:</b><br>Ability to pass Medi-Cal Certification, and Medicare training certification within 90 days of hire.</p><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Required:</b><br>Travel to offsite locations for work.</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>                    Medicare, Medicaid, Relationship Manager, Medical, Healthcare, Customer Service                                                    </p>

Health Plan Territory Representative II

<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Specialty Health Plans Auditor III is responsible all aspects of planning, execution, reporting and corrective action plans monitoring of financial solvency and claims processing compliance for specialty health plans and vendors. These audits are intended to ensure that L.A. Care delegates are in compliance with regulatory requirements and L.A. Care contractual agreements across all lines of business.</p><p>The position is responsible for the Department of Managed Health Care (DMHC) claims data submissions for L.A. Care and its Plan Partners (PPs) and delegates done each quarter and annually. &nbsp;Primarily responsible for the creation, review, and submission of departmental policies and procedures annually. </p><p>&nbsp;Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Performs financial audits and/or financial analyses for Specialty Health Plans on the quarterly and annual basis</p><p>Performs financial analyses or vendor’s management for L.A. Care vendors on the quarterly and annual basis.</p><p>Performs annual claims audits for Specialty Health Plans and vendors.</p><p>Provides timely and accurate deliverables to ensure financial solvency and claims processing compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors.</p><p>Collaborates in the creation and implementation of standardized Specialty Health Plans’ and vendors’ workpaper and reporting templates.</p><p>Collects and completes quarterly and annual (DMHC) filing submissions.</p><p>Is cross trained on financial solvency reviews for Participating Physician Group (PPGs), PPs, and capitated hospitals.</p><h4>Serves as primary contact and liaison for Centers for Medicare and Medicaid Services (CMS) claim audit section of L.A. Care delegates. </h4><h4>Reviews and updates annually the department’s Policies and Procedures (P&amp;Ps).&nbsp; Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission. </h4><h4>Supports the formalization of key internal processes and monitoring tools.</h4><h4>Accountable for the completion of requests from Legal Department, Delegation Oversight’s monitoring oversight and reporting.</h4><h4>Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors.</h4><h4>Collaborates on the design, implementation, and reporting of special projects</h4><h4>Duties Continued</h4><h4>Collaborates on the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.</h4><h4>Collaborates on the assessment, communication, and implementation of regulatory requirements that may impact internal processes.</h4><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><p>Performs other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Finance or Accounting or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 4 years of experience in conducting financial audits.&nbsp; </p><p>At least 5 years of related experience in the managed health care industry.&nbsp; </p><p><b>Preferred:</b></p><p>Health Care experience.</p><h4>Skills</h4><p><b>Required:</b></p><p>Excellent analytical and critical thinking skills.</p><p>Action-oriented, self-starter, and excellent motivator.</p><p>Excellent verbal and written communication skills.</p><p>Able to prioritize assignments, and able to independently with minimum supervision. </p><p>Ability to interface professionally with both internal and external customers at all levels of the organization.</p><p>Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).</p><h4>Licenses/Certifications Required</h4>And/Or any of the following Licenses/ Certifications:Certified Public Accountant (CPA)Certified Internal Auditor (CIA)Certified Fraud Examiner (CFE)Certified Management Accountant (CMA)<h4>Physical Requirements</h4>Light<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>                    Accounting, CPA, Claims, Internal Audit, Medicare, Finance, Insurance, Healthcare                                                    </p>

Specialty Health Plans Auditor III

<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 Financial Compliance Auditor III Finance is responsible for various tasks within the Financial Compliance Unit which include, but not limited to, performing, reporting, and corrective action plan monitoring of financial solvency reviews of plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors contracted with L.A. Care. This position is responsible for the overall financial solvency compliance on-going monitoring of assigned delegates across all lines of business including Medi-Cal, Covered California, D-SNP, and PASC-SEIU.</p><p>This position works closely with management and other team members on the identification and resolution of issues in a timely and efficient manner. This position leads assigned audits independently in accordance with general accepted auditing standards, generally accepted accounting principles (GAAP), regulations of the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and other federal and state guidelines. Responsible for the on-going communication, collaboration, and issue resolution on financial solvency issues with interdepartmental personnel, key stakeholders, and delegates.</p><p>&nbsp;Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Responsible for all aspects of financial solvency reviews including, but not limited to, the planning, execution, continuous monitoring, and reporting of annual financial audits, quarterly and annual financial analyses (ratio and trending analyses), and special projects.</p><p>Provides timely and accurate deliverables to ensure financial solvency compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors.</p><p>Collaborates the design, implementation, and reporting of special projects such as Medical Loss Ratio.</p><p>Collaborates the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.</p><p>Collaborates the assessment, communication, implementation of regulatory requirements that may impact internal processes.</p><p>Supports the formalization of key internal processes and monitoring tools with desktop procedures and applicable policies and procedures development.</p><p>Responsible for the financial audit team’s pre-delegation reviews and delivers monthly/quarterly request updates to various business units.</p><h4>Duties Continued</h4><p>Responsible for the completion and monitoring of monthly membership report.</p><p>Accountable for the completion of requests from Legal Department, Delegation Oversight’s monitoring oversight and reporting.</p><p>Communicates issues and findings in a concise and timely manner. </p><p>Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, and delegates.</p><p>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Finance or Accounting or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 4 years of experience performing financial audits.</p><p><b>Preferred:</b></p><p>Health Care experience.</p><h4>Skills</h4><p><b>Required:</b></p><p>Must be self-motivated.</p><p>Detail-oriented.</p><p>Excellent verbal and written communication skills.</p><p>Excellent analytical and critical thinking skills.</p><p>Able to prioritize assignments, and able to independently with minimum supervision.</p><p>Ability to interface professionally with both internal and external customers at all levels of the organization.</p><p>Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).</p><p>Must also have flexible mode of transportation for considerable amount of travel to work off-site.</p><h4>Licenses/Certifications Required</h4>And/Or any of the following Licenses/ Certifications:Certified Public Accountant (CPA)Certified Internal Auditor (CIA)Certified Medical Assistant (CMA)Certified Fraud Examiner (CFE)<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>                    Accounting, CPA, Internal Audit, Financial, Medicaid, Finance, Healthcare                                                    </p>

Financial Compliance Auditor III Finance

<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 Quality Improvement Training Specialist II assesses, develops, implements, and evaluates education and training programs to improve Consumer Assessment of Healthcare Providers and Systems (CAHPS), Medicare Stars, Medi-Cal Managed Care Accountability Set (MCAS), Quality Rating System (QRSR), and other quality programs. </p><p>The Quality Improvement Training Specialist II ensures that L.A. Care providers and staff are equipped with the information and training to understand major state and federal quality program requirements and how to deliver better service and care experience to members.&nbsp; </p><h4>Duties</h4><p>Perform assessments and evaluations to determine training needs and appropriate training methods for each topic and target audience.</p><p>Design and develop appropriate course content by applying knowledge of adult learning theory and work collaboratively with others as needed.&nbsp; </p><p>Deliver effective and scalable virtual, classroom, and online training programs to provider groups, provider offices, and L.A. Care staff as well as train the trainer sessions. </p><p>Evaluate training effectiveness and use data to regularly improve on training approach. </p><p>Maintain appropriate documentation and records of training conducted. </p><p>Adhere to all quality, compliance, and regulatory standards to improve outcomes. </p><p>Maintain updated professional and technical knowledge through continuing education. </p><p>Perform additional duties as assigned. </p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 3 years of experience in designing, developing, and delivering in person and online courses in a healthcare setting, preferably managed care setting.</p><p>Quality improvement experience with healthcare payers and/or providers.</p><p>Patient experience and CAHPs, HEDIS measure improvement experience.</p><h4>Skills</h4><p><b>Required:</b></p><p>Knowledge of CAHPs, HEDIS, and other quality measures. </p><p>Knowledge of quality improvement processes. </p><p>Knowledge of adult learning principles and how to apply them. </p><p>Strong facilitation and training skills in a virtual setting, group/classroom setting, and in-person. </p><p>Excellent interpersonal and presentation skills. </p><p>Excellent verbal and written communication skills.</p><p>Collaborating skills with the ability to build effective partnerships and collaboration with care providers, office staff, and internal L.A. Care staff.&nbsp; </p><p>Excellent organizational, decision-making, and multi-tasking skills.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Skills Required:</b></p><p>Solid analytical skills to conduct analysis and develop recommendations.</p><p>Ability to prioritize multiple and competing tasks and complete project tasks on schedule.</p><p>Ability to work independently and in a team environment.</p><p>Proficient with Microsoft Word, Excel, PowerPoint, and Outlook.</p><p>Strong motivation skills to proactively improve health care delivery and patient experience. </p><p>Demonstrated customer focus skills; proactively find ways to exceed customer needs.</p><p>Travel to offsite locations for work required.</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, Travel Nurse, Medicare, Healthcare                                                    </p>

Quality Improvement Training Specialist II

<p><b>Salary Range:&nbsp;</b>&nbsp;$47,840.00&nbsp;(Min.) -&nbsp;$57,062.00&nbsp;(Mid.) -&nbsp;$68,474.00&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 Solution Center Appeals and Grievances Coordinator I supports the Customer Solution Center Appeals &amp; Grievance Specialists by handling the administrative functions of the care management/continuity of care process including intake, logging, tracking and status follow-up.</p><p>This position collects information required by clinical staff to render decisions, assists the Customer Solution Center Appeals &amp; Grievance Manager and Director in meeting regulatory timelines by maintaining an accurate database inventory of care management and continuity of care cases, and preparing monthly activity reports.</p><p>In addition, the position performs data entry and processing of health risk assessments in the system, maintains confidentiality when communicating member information, and assists with the communication and coordination between programs. Prepares template determination/education letters for members and providers.</p><h4>Duties</h4><p><br>Provide non-clinical support to the Customer Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This includes the technical aspects of the time sensitive processes for initiating cases, managing referral documentation, entering &nbsp;pre-certification/continued authorizations, identifying and &nbsp;responding to urgency of &nbsp;the request, appropriate documentation, case routing &amp; tracking, routing of &nbsp;information, performing computer data input, faxing, filing of &nbsp;confidential member information, and maintaining logs of activity, etc.). &nbsp;(40%)</p><p>Assist in the telephonic outreach calls to members identified during health risk assessments as in needed of care coordination assistance. Consist of follow up calls to members to administer screening or obtaining clarification on initial responses. &nbsp;(25%)</p><p>Under the supervision of the Appeals and Grievance Manager, assist with soliciting non-clinical information from Participating Physical Group (PPG) and specialist concerning follow care related to care management. (15%)</p><p>Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director, ongoing referrals and authorizations &nbsp;for members in complex care management. (5%)</p><p>Accurately maintain an updated log of L.A. Care &nbsp;members identified as SPD or eligible with CCS cases. If members become ineligible with L.A Care or a specific program &nbsp;members are referred to Member Services for transition to other applicable &nbsp;programs". &nbsp;(5%)</p><p>Perform 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><h4>Experience</h4><p><b>Required:</b></p><p>At least 6 months of experience in Medi-Cal managed care authorization processes and/or as a Medical Assistant.</p><h4>Skills</h4><p><b>Required:</b><br>Knowledge of medical terminology and ICD-10 and CPT codes.&nbsp;</p><p>Strong verbal and written communication skills.</p><p>Proficiency with Microsoft Word, Excel, and Access.</p><p>Excellent organizational, interpersonal and time management skills.&nbsp;</p><p>Must be detail-oriented and an enthusiastic team player.&nbsp;</p><p>Knowledge of MHC computer system a plus.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Medical Assistant (CMA)<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>Medical, Dental and Vision</li><li>Wellness Program</li><li>Paid Sick Leave</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Data Entry, Medicare, Medical Assistant, Administrative, Healthcare                                                    </p>

Customer Solution Center Appeals and Grievances Coordinator I (Temporary)

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

Payment Integrity Nurse Coder RN III

<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 Managed Long-Term Services and Supports (MLTSS) Nurse Specialist RN II applies advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for L.A. Care members. Utilizes assessments, member-centered care planning, direct provider coordination/collaboration and psychosocial wraparound services to promote effective utilization of available Health Plan benefits including, but not limited to Community Based Adult Services (CBAS), Skilled Nursing Facility (SNF) services, Intermediate Care Facility for Developmentally Disabled (ICF/DD) services, CalAIM Community Supports, Palliative and Hospice Care. Scope of work includes care coordination functions and must adhere to regulatory mandates that apply to Utilization Management (UM) and Care Management (CM). </p><p>This position is responsible for assessing, planning, coordinating, and monitoring care needs to ensure members receive high-quality, cost-effective care that promotes independence and quality of life.&nbsp; The MLTSS Nurse Specialist RN II conducts comprehensive health assessments and is a member of an interdisciplinary team that is key in identifying the physical, psychological and social needs of the member.&nbsp; </p><p>The MLTSS Nurse Specialist RN II collaborates with Skilled Nursing Facilities (SNF), Intermediate Care Facility - Developmentally Disabled (ICF-DD), Community Based Adult Services (CBAS) Centers, Residential Care Facilities for the Elderly (RCFE), Preferred Provider Groups (PPG), CalAIM providers (i.e. Community Supports Vendors), Palliative and Hospice Care Providers and cross functional units to facilitate coordination of services. </p><h4>Duties</h4><p>Responsible for performing assessments and clinical review of medical records to determine appropriate care including physical health, behavioral health, and social determinants of health needs for members referred to; MLTSS administered programs.</p><p>Responsible for UM authorization functions for services requiring prior authorizations in a timely manner with adherence to regulatory requirements. Identify and address gaps in care or overutilization, including overlapping services.</p><p>Engages with members by conducting telephonic nursing follow up and care coordination when necessary, including transitions of care for Long Term Care (LTC) and ICF/DD populations.&nbsp; </p><p>Provides direction to non-clinicians who assist members with accessing services and arranges for all services required while coordinating with the health care team to eliminate duplication of services. </p><p>Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for MLTSS and other programs. </p><p>Establishes relationships with referral sources and community resources, such as external providers and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements.&nbsp; </p><p>Performs oversight and monitoring of provider performance for adherence to regulatory standards and contractual agreements. Participate in provider audits and quality improvement initiatives. Partners with Provider Network Management (PNM) and participates in Joint Operations Meetings (JOM). &nbsp;</p><h4>Duties Continued</h4><p>Facilitates care coordination with and provides education on available services to internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach minimizes member confusion, and ensures the best care is delivered in the most appropriate setting. </p><p>Documents accurately and comprehensively based on the standards of practice and current organization policies.</p><p>Performs other CM and UM functions as assigned and as needed /required by L.A. Care, to maintain regulatory requirements and company objectives. </p><p>Performs other duties as assigned.&nbsp;</p><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p><b>Required:</b></p><p>At least 3 years of clinical nursing experience in direct patient care, such as ambulatory care, home care, palliative care, hospice care OR experience in Utilization Review or Care Management will be considered in lieu of direct patient care that may include at least 2 years of relevant Licensed Vocational Nurse (LVN) experience in a UM or CM capacity substituted for 1 year of RN experience.</p><p>Clinical experience working with individuals with chronic illnesses, comorbidities, and/or disabilities in a UM/CM environment. </p><p><b>Preferred:</b></p><p>Experience in utilization review, skilled nursing, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies.</p><h4>Skills</h4><p><b>Required:</b></p><p>Excellent verbal and written communication skills; with effective charting practices. </p><p>Excellent organizational, time-management and priority-setting skills.</p><p>Strong clinical skills with a knowledge of care needs for elderly, disabled, and/or frail populations and has applied knowledge of End-of-Life care. </p><p>Customer Service Skills:&nbsp; Provision of excellent customer service required due to frequent communication with providers, members and interdisciplinary team.</p><p>Technical Skills: Must be computer literate and proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint, Teams).&nbsp; Ability to effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System.</p><p>Ability to maintain strict member confidentiality and complies with all HIPAA requirements.</p><p><b>Preferred:&nbsp;</b></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>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4>Certified Case Manager (CCM)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><br><b>Required:</b><br>Travel to offsite locations for work.</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>                    LVN, Nursing, Travel Nurse, Behavioral Health, Patient Care, Healthcare                                                    </p>

Managed Long Term Services and Supports Nurse Specialist RN 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 Customer Solution Center Appeals and Grievances (A&amp;G) Specialist II &nbsp;will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. &nbsp;The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.</p><p>The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.</p><h4>Duties</h4><p>Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.</p><p>Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment.&nbsp;</p><p>Ensures integrity of A&amp;G database by thorough, timely and accurate assignment of cases. &nbsp;Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.&nbsp;</p><p>Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.</p><p>Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. &nbsp;Recommends opportunities for improvement</p><p>Perform 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><b>Required:</b></p><p>At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.&nbsp;</p><p><br>Experience working with firm deadlines, able to interpret and apply regulations. &nbsp;</p><p>At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs. &nbsp;</p><p>Knowledge of Medical terminology and strong advocacy experience.</p><h4>Skills</h4><p><b>Required:</b><br>Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills. &nbsp;</p><p>A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.<br><br>Proficient in MS Office applications, Word, Excel and Power Point.&nbsp;</p><p>Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.&nbsp;</p><p><b>Preferred:</b><br>Proficient in MS Office applications, Access, Visio.</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>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>Medical, Dental and Vision</li><li>Wellness Program</li><li>Paid Sick Leave</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medicare, Claims, Medicaid, Healthcare, Insurance                                                    </p>

49 L.A. Care Health Plan Jobs