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<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Manager, Customer Solution Center Appeals and Grievances is responsible for the centralized intake, logging and triage process for all member appeals and grievances. The Manager oversees the resolution of member appeals and grievances for all product lines (Medi-Cal, Medi-Cal Direct, Medicare, PASC-SEIU and L.A. Care Covered) in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of Health Care Services, Centers for Medicare &amp; Medicaid Services, as well as requirements from the National Committee on Quality Assurance (NCQA) and L.A. Care policies and procedures. This position ensures the proper handling of member complaints whether presented by members, their authorized representative, the Ombudsman office, state contractors, member advocates, L.A. Care Board Members, providers, etc.</p><p>The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement.</p><p>Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management, Pharmacy, and Quality Management) to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate.</p><p>Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p><br>Manage and oversee the handling of member grievances and appeals, for L.A. Care and Plan Partner members as requested. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity. Review grievance and State Fair Hearing files for compliance with Policies and Procedures and directives. Review and monitor procedures for identifying quality of care issues and work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management, Quality Management, Pharmacy) to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management, Pharmacy) to appropriately address and resolve member and provider grievances.</p><p>Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhacements, among others.</p><p>Works with internal stakeholders to analyze monthly/quarterly grievance reports and PPG and Plan Partner data. Participates in Quality Oversight Committee, Member Service Quality Committee, and QI Improvement Committee and others as necessary.</p><p>Work collaboratively with state entities, providers, plans, community advocates, and key stakeholders (member representatives) to address cumbersome administrative issues negatively impacting members' access to care.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b></p><p>At least 5 years of experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and/or public services or public benefits programs.</p><p>At least 2 years of leading staff or supervisory/management experience.</p><p>Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations.</p><p><b>Equivalency:</b>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p><br><strong>Required:</strong><br>Strong customer service and excellent oral and written communication skills.&nbsp;</p><p>Health Plan background a plus, along with strong advocacy background.&nbsp;</p><p>Strong analytical and conflict resolution skills as well as persuasion skills.&nbsp;</p><p>Proficient in MS Office applications, Word, Excel, Power Point, and Access.</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>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, Pharmacy, Medicare, Medicaid, Healthcare, Insurance                                                    </p>

L.A. Care Health Plan

Manager, Customer Solution Center Appeals and Grievances

<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><h4>The Customer Solution Center (CSC) Appeals and Grievances (A&amp;G) Training Development Specialist III plays a key role in enhancing employee skills, knowledge, and performance by designing, developing, and facilitating high-impact learning programs.</h4><h4>The Specialist III designs and conducts training programs using established regulatory and departmental guidelines. This position focuses on building engaging and effective learning experiences through instructional design, content development, and live facilitation.</h4><h4>Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</h4><h4>Duties</h4><p>Responsible for providing ongoing training on the core processing system, Appeals and Grievance (A&amp;G) processing procedures, training regulatory changes that affect established procedures.&nbsp; </p><p>Provide ongoing training on the core processing system, A&amp;G processing procedures, training regulatory changes which will affect established procedures, working with the quality team on quality and performance guidelines, creating and maintaining departmental policy and procedures. </p><p>Evaluate initial training and ongoing learning opportunities to achieve consistency, efficiency, and productivity among the staff.</p><p>Work together with cross-functional teams to translate technical or complex content into accessible and engaging learning solutions.&nbsp; Work with the quality team on quality and performance guidelines, in creating and maintaining departmental policy and procedures.</p><p>Develop storyboards, scripts, and prototypes for digital and blended learning solutions.&nbsp; Use eLearning authoring tools (e.g., Articulate Storyline, Adobe Captivate, Rise 360) and Learning Management Systems (LMS) to deliver and manage content.</p><p>Design, develop, and deliver engaging learning content using instructional design best practices for in-person, virtual, and hybrid formats.&nbsp; Evaluate initial training and ongoing learning opportunities to achieve consistency, efficiency, and productivity among the staff.</p><h4>Duties Continued</h4><p>Facilitate CSC A&amp;G specific training sessions, workshops, and programs that support employee development, onboarding, leadership, and technical skill-building.&nbsp; Maintain documentation, including database/system updates, training agendas, sign-in sheets, etc. to demonstrate trainee compliance with department requirements.</p><p>Assess training effectiveness and learner performance using feedback, analytics, and learning assessments; iterate to improve content quality and outcomes.&nbsp; Identifies gaps in knowledge, skills and abilities, assess and recommend training/education measures to resolve issues and enhance staff performance.&nbsp; Propose program modifications to enhance performance and positively influence member satisfaction survey results.</p><p>Create and manage the A&amp;G courses for the Learning Management System (LMS), ensuring content is current, accessible, and engaging. Maintain A&amp;G specific training documentation, including database/system updates, training agendas, sign-in sheets, etc. to demonstrate trainee compliance with department requirements. Conduct assessments after A&amp;G specific training to measure, record, and report feedback on training material and sessions.</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>Review and recommends updates on policy and procedure critical to claims process.</p><p>Stay current on trends in adult learning theory, instructional design, and facilitation techniques.</p><h4>Perform other duties as assigned.</h4><h4>Education Required</h4>Bachelor's Degree in Education or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Related Field<h4>Experience</h4><p><b>Required:</b></p><p>At least 4 years of experience in adult learning, design and delivery of training programs.&nbsp; </p><p>Experience with both digital and instructor-led learning solutions.</p><p>Proven experience in instructional design and training facilitation.</p><p>Experience in Managed Care, Medicaid, Medicare experience.</p><p>Experience working in an Agile or fast-paced environment.</p><p><b>Preferred: </b></p><p>Experience with Appeals and/or Grievances.</p><p>Experience measuring learning effectiveness and applying data to improve content.</p><h4>Skills</h4><p>Proficient trainer skills. Knowledge of corporate training, onboarding, or compliance programs. Knowledge of adult learning principles and curriculum design methodologies. Ability and passionate about fostering a culture of continuous learning and growth.</p><p>Extensive knowledge and ability in curriculum development. Knowledge and understanding of accessibility and universal design principles. Proficiency in eLearning authoring tools and graphic/multimedia tools (e.g., Adobe Creative Suite, Camtasia). Proficiency in e-learning development tools (e.g., Articulate Storyline, Camtasia, Canva) and LMS platforms.</p><p>Strong platform skills with the ability to engage and inspire learners in both virtual and in-person environments. </p><p>Excellent attention to detail, organization, and time management. Ability to manage multiple projects with shifting priorities.</p><p>Excellent writing, visual design, and storytelling skills. Excellent written, verbal, and interpersonal communication skills. </p><p>Excellent team works still with the ability to achieve team goals.</p><p>Ability to conduct effective and engaging presentations in a variety of delivery settings.</p><p>Ability to interpret technical data, processes, operating and maintenance instructions and procedure manuals.</p><p>Strong analytical skills.</p><p>Must be flexible to meet the changing training needs.</p><p>Excellent Word, Excel, Power Point and Access skills.</p><p><b>Preferred:</b></p><p>Strong project management skills with the ability to manage multiple training initiatives simultaneously.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certification in Instructional DesignOrCertification in eLearning (e.g., Associate for Talent Development (ATD), Certified Professional in Learning and Performance (CPLP), Learning Experience Designed (LXD)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required to work after hours, weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>Required on 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>The ideal candidate is a dynamic trainer and curriculum developer who is passionate about fostering a culture of continuous learning and growth across the organization</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>                    Learning, Medicaid, Medicare, Claims, Human Resources, Insurance, Healthcare                                                    </p>

Customer Solution Center Appeals and Grievances Training Development Specialist 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 Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.</p><h4>Duties</h4><p>Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.</p><p>Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. </p><p>Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.</p><p>Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.</p><p>Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. </p><p>Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner.</p><h4>Perform other duties as assigned. </h4><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><br>At least 5 years of varied RN clinical experience in an acute hospital setting.</p><p>At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting .&nbsp;</p><p><b>Preferred:</b><br>Managed Care experience performing UM and CM at a medical group or management services organization.</p><p>Experience with Managed Medi-Cal, Medicare, and commercial lines of business.</p><h4>Skills</h4><p><b>Required:</b><br>Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. &nbsp;Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate &nbsp;software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials.&nbsp;</p><p>Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team &nbsp;<br><br>Excellent time management and priority-setting skills.</p><p>Maintains strict member confidentiality and complies with all HIPAA requirements.</p><p>Strong verbal and written communication skills. &nbsp; &nbsp;</p><p><b>Preferred:</b><br>Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM).&nbsp;</p><p>Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.</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>May work on occasional weekends and some holidays depending on business needs.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Medicare, Medicaid, Claims, Healthcare, Insurance                                                    </p>

Utilization Management Nurse Specialist RN II

<p><b>Salary Range:&nbsp;</b>&nbsp;$67,186.00&nbsp;(Min.) -&nbsp;$87,342.00&nbsp;(Mid.) -&nbsp;$107,498.00&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 Behavioral Health Operations Specialist II is responsible for supporting, coordinating and facilitating several areas of the Behavioral Health Department. This position assists members with accessing Behavioral Health services and provides guidance and support to members encountering complex needs when navigating the health care system. This position also provides support with collecting and analyzing data from behavioral health vendor, County Department of Mental Health, Public Health and direct Applied Behavioral Analysis (ABA) providers. This position provides support with submitting required reporting elements in a timely fashion to regulatory organizations. Furthermore, the Behavioral Health Operations Specialist also facilitates providers with technical and logistical guidance when coordinating with internal and external stakeholders. This position supports the department with behavioral health related quality improvement, compliance, and regulatory support within the Behavioral Health Treatment Program and Clinical teams. </p><h4>Duties</h4><p>Day to day vendor and member support including, but not limited to, trainings, education and information to vendors and responding to all vendor related inquiries.&nbsp;</p><p>Provides program support for the department to ensure successful development/implementation of existing and emerging initiatives. Coordinate and assist with logistics for assigned tasks/activities, develop written communications, presentations as needed.&nbsp;</p><p>Works collaboratively with the ABA and Clinical teams to ensure compliance and smooth business operations.&nbsp;</p><p>Analyzes and resolves complex problems dealing with grievances and appeals. Provide policy and procedure interpretation and implement processes. Coordinates and leads regular meetings with vendors, track and analyze metrics, lead solutions and review/audit files, to improve health outcome care measures and provide status reports to management and business partners.</p><p>Supports with Healthcare Effectiveness Data and Information Set (HEDIS), National Committee for Quality Assurance (NCQA) and Quality Improvement (QI) reporting, audit preparation and data collection.</p><p>Works to support other Behavioral Health Department projects and initiatives.</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><b>Required:</b></p><p>At least 4 years of provider services/relations experience in a healthcare field, including behavioral health related field or medical group.</p><p>Experience providing excellent customer service.</p><h4>Skills</h4><p><b>Required:</b></p><p>Work proactively in collaborate team environment. </p><p>Strong organizational, multi-tasking and time management skills.</p><p>Strong written and verbal communication skills.</p><p>Ability to lead and present in small and large group settings.</p><p>Essential computer skills. Proficient with Microsoft Office, especially Word and Excel. </p><p>Ability to be flexible as position evolves with the needs of the department and new developments at the State and Federal level.</p><p>Knowledge of file review/auditing.</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, Public Health, Counseling, Medical, Healthcare                                                    </p>

Behavioral Health Operations Specialist II

<p><b>Salary Range:&nbsp;</b>&nbsp;$121,056.00&nbsp;(Min.) -&nbsp;$160,400.00&nbsp;(Mid.) -&nbsp;$199,742.00&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 Information Security (InfoSec) Engineering and Architecture (ISEA) Engineer III follows a “Security by Design” Methodology ensuring Security is built-into products, technologies, SaaS solutions, etc. in the early phases of a technology or solution implementation. This position engineers, implements, and maintains information security systems and controls for L.A. Care Health Plan. </p><p>The ISEA Engineer III works closely with the Cyber Defense Operations Center (CDOC) Analysts and the various departments and technical staff within Information Technology (I.T.). This position collaborates with business units on the front end in the build of a new solution to ensure security measures are in place from the beginning of the project. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Ensures all InfoSec tools are configured appropriately. Ensures all InfoSec tools are capturing and displaying the most relevant and actionable information the tool is designed to deliver. Ensures all InfoSec tools are running at their current supported versions.</p><p>Proactively develops and enforces security plans and standards to maintain the confidentiality, integrity, and availability of the organization’s and member’s data.</p><p>Interfaces directly with technical and business staff to design and implement security architectures to protect LA Care information assets.</p><p>Develops systems and processes to prevent information and infrastructure breaches.</p><p>Designs and implements elegant solutions to complex security and risk problems.</p><p>Applies appropriate technologies while following security engineering best practices.</p><p>Fosters constructive dialogue and problem resolution when confronted with differing viewpoints on security risks.</p><p>Conducts research to identify attack vectors against the organization. Identifies and assesses vulnerabilities and risks to enterprise applications, infrastructure, and data. Develops and implements technical solutions to counter vulnerabilities and risks.</p><p>Develops plans for incident response.</p><h4>Duties Continued</h4><p>Acts as the technical expert in multiple domains to lead the Information Security team during incident and breach responses.</p><p>Leads security projects (including security reviews, tool development, and creation of new security practices) with end-to-end ownership. Provides security consulting services to various projects.&nbsp;</p><p>Creates security guidance and documentation. Develops security tools and automation.</p><p>Supports the enterprise data loss prevention program by identifying and controlling data loss channels.</p><p>Works with IT and business units to address their data loss prevention requirements.</p><p>Provides on-call support on a rotational basis as part the Information Security team.</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 &nbsp;meets the needs of the department, and organization &nbsp;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 Science or TechnologyIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b><br>At least 6 years of experience in a senior Information Security role.</p><p>Operational experience configuring and managing a Security Information and Event Management (SIEM) platform.</p><p>Operational experience using and configuring a vulnerability management platform.</p><p>Operational experience using a static application security testing platform.</p><p>Operational experience assessing and securing cloud computing environments (e.g., AWS, Azure, etc.).</p><p><b>Preferred:</b><br>Operational experience building or reviewing threat models.</p><p>Operational experience in a regulated environment (e.g., classified networks, healthcare, finance, banking, etc.).</p><h4>Skills</h4><p><b>Required:</b><br>Strong working knowledge in one or more of the following disciplines: DevOps, Digital Forensics, Penetration Testing, Programming (Java preferred), and/or System or Network Administration.</p><p>Working knowledge of data loss prevention (DLP) toolsets.</p><p>Strong understanding of networking and communication protocols (such as TCP/IP, UDP, SSL/TLS, IPSEC, HTTP/S, etc.).</p><p>Understanding of web service frameworks and service architectures (such as event-driven, service-oriented, or server less architectures).</p><p>Ability to collaborate with internal and external key stakeholders.&nbsp;</p><p>Combination of strong troubleshooting, technical, and communication 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>Professional Certifications</b></p><p><b>Preferred:</b><br>One or more of:&nbsp;<br>Certified Information Systems Security Professional (CISSP)<br>Certified Ethical Hacker (CEH)<br>Certified Hacking Forensic Investigator (CHFI)<br>GIAC Certified Detection Analyst (GCDA)<br>Offensive Security Certified Professional (OSCP)</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                                                </p>

Information Security Engineering and Architecture Engineer III

<p><b>Salary Range:&nbsp;</b>&nbsp;$121,056.00&nbsp;(Min.) -&nbsp;$160,400.00&nbsp;(Mid.) -&nbsp;$199,742.00&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>As part of the Information Technology team, the Principal Business Intelligence Engineer is responsible for designing, engineering and leading Business Intelligence (BI) solutions. This position ensures business intelligence solutions developed are robust, scalable and align with target architecture. Responsibilities include, but are not limited to, requirements gathering, data analysis, design and building business intelligence solutions.</p><h4>Duties</h4><p>Accomplishes data and reporting architectural goals by leading and designing BI solutions; focused on self-serve models.</p><p>Promotes and educates the enterprise on all-things Business Intelligence and Reporting.</p><p>Oversees BI solutions developed by the IT organization to ensure alignment with target architecture.</p><p>Collaborates with business users on reporting solutions.</p><p><br><br>Mentors BI developers to ensure solutions are scalable and maintainable.</p><p>Develops and implements BI and reporting standards.</p><p>Evaluates and recommends business intelligence, reporting and analytics tools.</p><p>Partners with leadership to evolve the BI strategy and roadmap.</p><p>Completes projects by coordinating resources and timetables with user departments and other IT teams.</p><p>Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.</p><p>Contributes to team effort by accomplishing related results as needed.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Computer Science or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b></p><p>At least 6 years of experience developing Business intelligence solutions for large enterprises.</p><p>Hands-on experience with BI tools (ex: OBIEE, BI Publisher, Tableau).</p><h4>Skills</h4><p><b>Required:&nbsp;</b></p><p>Knowledgeable in Data and Reporting Architecture.&nbsp; </p><p>Proficient in Data Modeling, Data Architecture, Data Analysis, Data profiling and SQL.</p><p>Effective Problem Solving skills.</p><p>Effective Written and Verbal communication skills.</p><p>Excellent teamwork skills. </p><p>Ability to develop, foster and maintain open, professional relationships with other team members and customers to enhance customer satisfaction. </p><p>Expert understanding of BI concepts.</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                                                </p>

Principal Business Intelligence Engineer

<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><br>The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines.</p><p>Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases, which are those with the severest acuities or care needs and requiring the highest clinical skills and judgement. &nbsp;Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner.&nbsp;</p><p>Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team. Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member information, document contacts, and track member progress.&nbsp;</p><h4>Duties</h4><p>Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs.</p><p>Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives; reviewing member claims histories and identifies intervention opportunities through the professional standards of practice; contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits; conducting comprehensive clinical assessments as indicated; developing a member centric plan of care. Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence).&nbsp; </p><p>Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies.</p><p>Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions.</p><h4>Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.</h4><h4>Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes.</h4><h4>Duties Continued</h4><h4>Meets and assesses members at L.A. Care Community Resource Centers, as needed.</h4><h4>Provides effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines.</h4><h4>Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate.</h4><h4>Encourages member and family empowerment through education and use of reliable resources.</h4><h4>Monitors and evaluates member progress: evaluates member response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assesses effectiveness of care plan’s goals and interventions on a regular basis.</h4><h4>Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member's clinical records to promote care coordination. </h4><h4>Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage.</h4><h4>Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training.</h4><h4>Performs other duties as assigned.</h4><h4>Education Required</h4>Associate's Degree in Nursing for Registered NursesMaster's Degree in Social Work for Licensed Clinical Social Workers<h4>Education Preferred</h4>Bachelor's Degree in Nursing for Registered Nurses<h4>Experience</h4><p><br><strong>Required:</strong><br>Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments. &nbsp;</p><p>Experience providing care management with complex/catastrophic conditions.</p><h4>Skills</h4><p><br><b>Required:</b><br>Current knowledge of clinical standards of care and disease processes.</p><p>Critical thinking skill.&nbsp;</p><p>Excellent customer service skills.</p><p>Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions.</p><p>Ability to triage immediate member health and safety risks.</p><p>Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping.</p><p>Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders. &nbsp;</p><p>Ability to use a personal computer, and knowledge of medical information systems.</p><p>Knowledge of and ability to comply with HIPAA compliance.</p><p>Ability to interview, assess and coordinate care. Ability to prioritize caseload.</p><p>Knowledge of community resources.</p><p>Knowledge of Medi-Cal and Medicare regulations.</p><p>Ability to work as a part of a diverse team and gain consensus and resolution of problems.</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>Registered Nurse (RN);current and unrestricted California License OR Licensed Clinical Social Worker; 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><b>Required:&nbsp;</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>                    Social Worker, Nursing, Registered Nurse, Behavioral Health, Substance Abuse, Service, Healthcare                                                    </p>

Care Management Specialist II (D-SNP)

<p><b>Salary Range:&nbsp;</b>&nbsp;$121,056.00&nbsp;(Min.) -&nbsp;$160,400.00&nbsp;(Mid.) -&nbsp;$199,742.00&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 Technical Application Manager II reports to the Senior Manager Information Technology I.T. Solutions Delivery. This role acts as the Technical Leader enterprise-wide for the assigned Domain, overseeing design, delivery, integration and support. This person should have a strong understanding of related Business Processes, corresponding I.T. Systems, Data Interfaces and Regulatory Requirements.&nbsp;</p><p>This person needs to quickly gain working knowledge of L.A. Care Domain Business Practices and Information Technology Solutions, including the identification of gaps between current business need and system functions. Additionally, this person needs to develop a Solutions Delivery plan for meeting current and anticipated Domain needs; this plan includes Application Roadmaps, Staffing Model (FTE and Consultant), SOA Service Definition, Data Management/Interfaces. This position works closely with the Business Domain leads, Business Relationship Managers, Security, Infrastructure, Quality Assurance, Production Support, Business and Technical Architecture teams.</p><p>The candidate should be well-organized, flexible and capable of driving accountability within the Solution Delivery Domain for all system functionality and performance. This person needs to manage ambiguity, negotiates optimal approaches, prioritizes and remediates in a complex and dynamic environment. This person needs to demonstrate an ability to manage Commercial Software Vendor relationships and Consulting teams in support of Domain Solution needs. This person also oversees any escalated Production Support issues for Domain Solutions.</p><p><br>The ideal candidate has demonstrable experience in overseeing and delivering I.T. Solutions, preferably in the Provider Network Management space.</p><p>• Understand how each System (Commercial or Custom) capability meets the Processing and Information requirements to implement business functions effectively<br>• Be aware of all major Initiatives (Programs, Projects, Service Requests) that require enhancements or customizations to Domain Systems<br>• Drive all interface requirements (Service Bus, EDI, File Processing, Portal etc.) from each Domain System<br>• Provide Level 3 Production Support for each Domain System<br>• Drive all Consulting/Contractor enhancements and customizations to Domain Systems<br>• Manage System Roadmaps (Upgrades, Customizations, Configurations, Replacements, Retirements)<br>• Participate in Impact Assessments to determine Domain System impact to new Enterprise Initiatives.</p><h4>Duties</h4><p>Document current and future state Domain System Process Flow, Data Flow and Interfaces.</p><p>Provide technical direction to Business Systems Analysts, Technical Leads, Development Staff comprised of Full Time Employees and Consultants. Act as liaison between IT Solution Delivery team and Program/Project Managers for all Enterprise Initiatives.</p><p>Manage and prioritize backlog of Solutions Delivery Domain service requests and maintenance work.</p><p>Develop and manage Domain Application Roadmaps including System Configurations, Functions, Service Bus Integrations, Data/File Integrations, Monitoring and Security milestones.</p><p>Manage Solutions Delivery Domain Software and Consulting vendors.</p><p>Provide ‘escalated’ Production Support and Incident Management.</p><p>Perform Impact Assessments and Solution Reviews for Solutions Delivery Domain.</p><p>Assist in Enterprise Roadmap Planning Activities, Business and Enterprise Architecture.</p><p>Perform other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Computer ScienceIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b><br>Minimum of 6 years of I.T. Applications work experience with 4 years of progressive technical oversight.</p><p>At least 5 years developing Software Solutions leveraging a Software Development Lifecycle Methodology.</p><p>At least 4 years of specified Domain experience, see attached addendum.</p><p>At least 4 years of I.T. Vendor (Software and Consultant) Management.</p><p><b>Preferred:</b><br>At least 3 years of Production Support experience.</p><p>At least 3 years of Health Plan I.T. experience.</p><p>At least 3 years of Service Bus development experience.</p><h4>Skills</h4><p><strong>Required:</strong><br>Technical leadership, Application Roadmaps, Vendor Management (Software Product and Labor).</p><p>Well-organized, flexible and self-starter.</p><p>High level of written and verbal communication skills.</p><p>Strong decision making ability and attention to detail.</p><p>Ability to influence key internal and external business/IT partners.</p><p>Active listening skills.</p><p>Ability to understand complex technical issues.</p><p>Ability to navigate ambiguity and proactively develop effective plans.</p><p>Ability to create Application Architecture diagrams and Roadmaps.</p><p>Agile Development.</p><p><strong>Preferred:</strong><br>Program/project management skills.</p><p>Microsoft Project Server, Excel, PowerPoint, Word.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Department Specifics:</b></p><p><b>Finance:</b><br>Minimum of 4 years of Financial Services Domain experience required.<br>Critical Thinking Skills (Analyzing, Logical Reasoning, Predicting, Transforming Knowledge and Applying Standards) required.<br>Functional knowledge of Financial (Accounting Principles and Theory) preferred.</p><p><b>Health Services</b><br>Minimum of 4 years of Health Services Domain experience required.<br>3 years of Clinical Care and 3 years of HIE, HEDIS experience preferred.<br>Functional knowledge of HEDIS, HIE, Health Analytics required.<br>Functional knowledge of Utilization Management, Care Management, Clinical Case Management, Disease Management preferred.</p><p><b>Provider Domain TPM</b><br>Minimum of 4 years of Provider Data Management Domain experience required.<br>3 years of Provider Network experience preferred.<br>3 years of Provider Data experience preferred.<br>3 years of Service Bus development experience, Micro services (Mulesoft), NoSQL (MarkLogic), Informatica Data Quality, Informatica MDM, Tableau, Informatica (AXON), Oracle database preferred.<br>Functional knowledge of Provider Data Management, Provider Network Management preferred.</p><p><b>Customer Relationship Management/Salesforce Surround Systems:</b><br>Minimum of 4 years of CRM Domain and integration experience required.<br>3 years of Service Bus development experience preferred.<br>Functional knowledge of CRM (Salesforce) preferred.</p><p><b>Clinical Services</b><br>Minimum of 4 years of Health Services Domain experience required<br>Minimum of 4 years of Clinical System experience (e.g. Clinical Care Advance, ZeOmega, Altruista, Thrasys) required.<br>Functional knowledge of Utilization Management, Care Management, Clinical Case Management, Disease Management required.<br>Functional knowledge of HEDIS, Health Information Exchange preferred.</p><p><b>Membership</b><br>Minimum of 4 years of Health Plan Membership Domain experience required.<br>Functional knowledge of Membership Eligibility and Enrollment, Member Maintenance, PCP assignment, Appeals and Grievances preferred.</p><p><b>EDI</b><br>5 years of EDI Domain experience required.<br>5 years of HIPAA X12 standards experience preferred<br>Functional knowledge of all aspects within the HIPAA Administration Simplification Rule, including the transaction operating rules preferred.<br>Functional&nbsp;&nbsp;knowledge of basic industry protocal mapping tools, such as Edifecs, IBM WEBSPHERE , etc. preferred.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Relationship Manager, Customer Service                                                    </p>

Technical Applications Manager 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><br>The Lead Customer Solution Center Service Representative is responsible for the development of a successful and cohesive Call Center unit, with a high level of productivity to achieve the department's overall performance metrics, and to meet and/or exceed member satisfaction. Assist Call Center Supervisors with the supervision of Member Services Representatives by closely monitoring performance, which includes but not limited to: coaching, mentoring, motivating, counseling, etc. to ensure they are providing optimal customer services and meeting and/or exceeding department goals.&nbsp;Responsible for the daily workflow and leading the work of assigned staff.</p><h4>Duties</h4><p>Leadership of day to day activities of Member Services Representatives, including but not limited to: Providing direction. Monitoring of staff performance including attendance. Handling all questions/issues raised by staff. Recommending process improvement processes. Preparing and analyzing call center statistical reports. Monitoring/Adjusting of skill-sets for consistency. Ensuring quantity/quality is met for overtime. Handle escalated calls. Back-up to calls as needed. Assist Supervisor to ensure that Representatives provide accurate, timely and quality service to our members/providers. Ensure that all departmental policies, procedures and standards are being met, as well as the organization's mission. Assist Supervisor to ensure that deviations in performance are identified in advance and process changes are made to redirect performance to acceptable levels. Assist Supervisor to ensure that we provide accurate, timely and professionally written, statistical and verbal reports to management for historical, current status and forecasting purposes. Assist Supervisor in reviewing the Representatives overall quality accuracy. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. (40%)</p><p>Trains and motivates staff. Ensures appropriate service standards are developed and maintained. Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training and feedback on performance to department management.&nbsp; Oversees the daily office workflow, develops and recommends enhancements to process and procedures.&nbsp;&nbsp; (5%)</p><p>Work with training staff to ensure that training practices support staffing and performance standards, takes responsibility for identifying on-going training needs and integrating training and performance expectations as well as work closely with Supervisors to create and/or modify Desk top procedures. (5%)</p><p>Work closely with management to review performance and quality standards on an ongoing basis and to assist with development and implementing incentive programs. As well as motivational programs needed to achieve service standards. (10%)</p><p>Ensures that front line service personnel are capturing information and providing feedback to Supervisors that will enable L.A. Care to improve its product and internal process. (10%)</p><h4>Duties Continued</h4><h4>Represents the Department when requested at meetings. Assist Supervisor with meetings and provides necessary feedback when requested. (5%)</h4><h4>Ensure department remains in compliant with HIPAA regulations relating to protected health information (PHI). (10%)</h4><h4>Maintains attendance expectations. (5%)</h4><h4>Perform other duties as assigned. (10%)</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 2 years of customer service experience.</p><p>At least 6 months of lead experience in a health plan/ healthcare customer service call center environment.</p><p><b>Preferred:</b></p><p>Experience in working with the disadvantage population, Covered California, and Cal MediConnect.</p><h4>Skills</h4><p><b>Required:</b><br>Must have knowledge in direct line of business.&nbsp;<br><br>Must know Medical Terminology.</p><p>Must have excellent written and verbal communication skills.</p><p>Strong analytical, coaching/mentoring skills, team building.<br><br>Ability to work effectively with diverse team members.<br><br>Must also have the ability to troubleshoot problem areas and recommend effective alternative solutions to handle irate callers, and provide optimal customer service for internal and external customers.</p><p>Must be flexible with time and be able to work overtime including weekends.&nbsp;</p><p>Must be able to multitask and to streamline day to day operations, policies and procedures.</p><p>Must have advance PC skills including Excel and Access.</p><p><b>Preferred:</b><br>Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Call Center Representative, Customer Service Representative, Call Center, Customer Service                                                    </p>

Lead Customer Solution Center Service Representative

<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, Care Management is directly responsible for the oversight and monitoring of care management functions, organization, direction and staffing of L.A. Care's Case Management function(s) including but not limited to Complex Case Management/Case Management, Care Coordination and Special Programs Outreach. Responsibility includes regulatory compliance, accreditation compliance, oversight of Plan Partners' and Delegated Provider Groups related operations, oversight of&nbsp; care management related delegated functions, operations for direct lines of business and/or management services agreement functions, and interfacing with external agencies including other Local Initiatives, Plan Partners and external organizations. The Manager, Case Management is further responsible to assure all functions are operating in accordance with the organization's mission, values and strategic goals and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>General Essential functions: Responsible for the ensuring overall staff management and operational functions &nbsp;associated with the Care Management department. Functions include Complex Case Management, Case Management, Care Coordination, and Special Programs (i.e. CCS, Regional Center) functions. Assures departmental compliance with: &nbsp;All contracts (i.e. CMS, DHCS, Covered California, PASC-SEIU, First 5LA, etc.), DMHC regulations, applicable state and federal regulations, Management Services Agreements &amp; Other Contracts. Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements. Assures department meets all regulatory time frames on CM. Develops and implements departmental policies and procedures. Develops and maintains departmental statistical and performance reports. Develops, implements and monitors performance standards. Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations. Develop and maintain departmental budgets in line with organizational goals. Ensuring the maintenance of positive relationships between Plan Partners and PPGs. Identifies and implements, with approval, programs that improve the provision of services to members. Directs measurement and analysis of Plan Partner and delegated PPG functions. &nbsp;Assures completion of ongoing monitoring, audits, corrective action plan and necessary follow-up. Facilitates communication to and involvement of Plan Partners. Assures appropriate communication and coordination with CBOs and other external agencies. Facilitates data flow, analyzes, reports, design formats, interprets data and recommends alternatives/solutions internally and externally. Requests assistance from Director as needed to accomplish goals.</p><p>Maintains confidentiality in compliance with all HIPAA requirements. Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner. Demonstrates reliability and good attendance and punctuality standards.</p><p>Human Resource Management: Daily staff supervision and oversight. Develops and maintains a culturally sensitive work environment that promotes staff growth and education. Completes performance appraisals in accordance with established policies and based upon achievement of the L.A. Care mission, value, objectives and management expectations. Assures staff have access to appropriate training and educational opportunities. Recruits appropriately qualified candidates, with approval of Director. Counsels and coaches staff in consultation with Director and in conjunction with HR. Participates in the hiring and termination of staff with Director and in conjunction with HR.</p><p><br>In conjunction with Director of CM, responsible for oversight and adequate performance of direct line of business PPG delegated activities. Develops and sustains active communications with PPGs. Identifies performance issues or opportunities for improvement within PPG UM operations that impact compliance. Collaborates with Oversight Staff on identifying topics and agenda items for the PPG trainings/JOMs.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Master's Degree in Social WorkOr Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p><b>Required:&nbsp;</b><br>At least 4 years of recent care management experience in a hospital or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.</p><p>At least 3 years of management/supervisory experience and relevant health plan experience.</p><p>Experience with Medi-Cal and Medicare populations and regulatory requirements.</p><p><b>Equivalency:</b>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p><b>Preferred:&nbsp;</b><br>Experience with Medi-Cal, under-served and culturally diverse populations.</p><p>Experience with state Medi-Cal regulations.</p><p>Audit/oversight experience.</p><h4>Skills</h4><p><strong>Required:&nbsp;</strong><br>Excellent verbal and written communication skills.</p><p>Strong problem solving, planning, and organizational skills.</p><h4>Licenses/Certifications Required</h4>Licensed Clinical Social Worker (LCSW); Current and unrestricted California License or Registered Nurse (RN); current and unrestrited 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>Please note that a Licensed Clinical Social Worker is only required when Master's Degree in Social Work. Licensed Clinical Social Worker not required with Associate's or Bachelor's Degree in Nursing.&nbsp;</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>                    Social Worker, Registered Nurse, Nursing, Palliative, Medicare, Service, Healthcare                                                    </p>

49 L.A. Care Health Plan Jobs