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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><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>

L.A. Care Health Plan

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;$105,267.00&nbsp;(Min.) -&nbsp;$139,478.00&nbsp;(Mid.) -&nbsp;$173,689.00&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 Technology (IT) Development Operations (DevOps) Engineer II plays a key role in implementing and maintaining automation processes to streamline our software development and deployment pipelines. </p><p>This position maintains and enhances the Continuous Integration and Deployment (CI/CD) pipelines ensuring the reliability, scalability and efficiency of L.A. Care's software delivery pipeline. </p><p>This position fosters a culture of collaboration between the development and operations teams, automates manual processes, and improves the efficiency, reliability, and scalability of software delivery.</p><h4>Duties</h4><p>Continuous Integration and Deployment (CI/CD): Build and maintain CI/CD pipelines using tools like Jenkins, GitAction CI/CD. Implement automated testing and deployment processes to ensure rapid and reliable delivery of software releases.</p><p>Monitoring and Logging: Configure and manage monitoring and logging solutions to ensure the health and performance of systems and applications. Analyze metrics and logs to troubleshoot issues and optimize system performance.</p><p>Collaboration and Documentation: Collaborate with development and operations teams to identify automation opportunities and streamline workflows. Document infrastructure and processes to facilitate knowledge sharing and ensure system reliability.</p><p>Security and Compliance: Implement security best practices and compliance standards in infrastructure and deployment processes. Conduct regular security assessments and audits to identify and vulnerability Management. Process, report and audit using the Version Control System (VCS) Access control. </p><p>Infrastructure Automation: Design, implement, and maintain infrastructure as code (IaC) solutions using tools such as Terraform, Ansible, or Chef. Automate deployment, scaling, and monitoring of cloud-based infrastructure on platforms like Azure.</p><p>Focus on the intersection of software development (Dev) and IT operations (Ops), aiming to improve collaboration and productivity across these functions. Responsible for automating infrastructure provisioning, configuration management, monitoring, and scaling of applications and systems.</p><p>Work closely with cross-functional teams, including developers, system administrators, and quality assurance engineers, to ensure seamless software delivery and system reliability.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Information Technology 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 5 years of experience as a DevOps Engineer or similar role. </p><p>At least 3 years of experience in source code management and administration.</p><p>Experience in version control systems (VCS), such as GITHUB GIT Action, Application Development Interface (ADI), and Subversion (SVN).</p><p>Experience in CI/CD tools such as GIT Action, Azure DevOps (ADO) CI/CD tools and integration of VCS with development pipelines.</p><p>Experience with security best practices related to source code management.</p><p><b>Preferred:</b></p><p>Hands on experience managing infrastructure as code (IaC) and Containerization and Orchestration.</p><h4>Skills</h4><p><b>Required:</b></p><p>Strong understanding of branching strategies, code versioning, and merge conflict resolution in ADO, GITHUB.</p><p>Strong understanding of GIT Action capabilities to develop and manage CI/CD pipelines.</p><p>Strong scripting skills using power Shell, Python, or other relevant languages.</p><p>Strong knowledge of code quality tools and practices. </p><p>Must have skills to configure new tools.</p><p>Must have a broad range of skills including scripting and programming, cloud infrastructure (AWS, Azure, etc.), containerization (Docker, Kubernetes), and orchestration tools.</p><p>Excellent problem-solving and troubleshooting skills.</p><p>Strong communication and collaboration skills.</p><p>Detail-oriented and organized with a commitment to maintaining data integrity.</p><p>Strong teamwork abilities.</p><p>Must be a self-starter with the ability to build processes from ground level.</p><p>Good understanding of networking, security, and best practices for cloud and on-premises infrastructure.</p><p>Exposure to monitoring and troubleshooting applications and infrastructure.</p><p>Expertise in cloud computing platforms such as Azure, AWS or Google Cloud.</p><p>Excellent leadership skills, with the ability to influence and inspire cross-functional teams.</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><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 Technology Development Operations Engineer II

<p><b>Salary Range:&nbsp;</b>&nbsp;&nbsp;(Min.) -&nbsp;$10.00&nbsp;(Mid.) -&nbsp;&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 Customer Solution Center Service Representative I is responsible for a successful completion of the Member Services training program and continues to gain strong knowledge of Medi-Cal and Personal Assistance Services Council (PASC) managed care product lines.&nbsp;</p><p>The Customer Solution Center Service Representative I handles first level calls involving member eligibility verification, general program and administration questions, benefits and services, member requests for I.D. cards and Primary Care Provider (PCP) changes, and triage of calls to appropriate units or outside entities.&nbsp;</p><h4>Duties</h4><p>Answers incoming first level calls from members, potential members, providers and advocates. Handles and resolves member issues, assists members in connecting with internal units or external parties such as Plan Partners, Primary Care Physician (PCP) offices, pharmacists, etc. Provides essential information to members regarding access to care issues, coordination of care issues, benefits, Evidence of Coverage (EOC), Member Handbook, etc. Assists providers in using the Interactive Voice Response (IVR) web portal and verifying member eligibility. Documents all calls via the member data base system, QMEIS.&nbsp;<br>Ensures department compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations relating to protection of personal history information. Troubleshoots and directs calls to the appropriate departments or outside entities. (75%)</p><p>Supports robocall and ad-hoc member outreach activities as determined by business need. (15%)</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><br>At least 6 months of customer service call center experience.&nbsp;</p><p>Data entry experience with ability to type a minimum of 40 words per minute.&nbsp;</p><p><b>Preferred:</b><br>Managed care or health plan experience.</p><h4>Skills</h4><p><b>Required:</b><br>Ability to answer a high volume of calls.</p><p>Knowledge of medical terminology.&nbsp;</p><p>Must be a strong team player, punctual, and has excellent attendance record.&nbsp;</p><p>Good understanding of service to the disadvantaged population, seniors and or people with chronic conditions or disabilities.&nbsp;</p><p>Must be a quick learner, excellent team player and customer service oriented.</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. &nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>L.A. Care Health Plan Call Center is available 24 hours a day, 7 days a week, including holidays. Call Center work shifts are assigned based on business need and may include, but not be limited to, evenings, weekends and holidays.</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>                    Call Center Representative, Customer Service Representative, Call Center, Data Entry, Customer Service, Administrative                                                    </p>

Customer Solution Center Service Representative I

<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><br>The Manager, Technology Application Production Support and Control will report to Director, Production Support within the IT Quality Assurance and Process excellence organization and will be primarily responsible for Batch Support and Major Incident Management. The Manager will provide end to end support for all on premise L.A. Care software applications and coordinate support with vendors for off-premise/hosted applications. The Manager will ensure all Production incidents and Service Requests are handled within the LA.Care defined SLAs using ITIL processes. &nbsp;This position will collaborate with Business and various IT teams like Infrastructure, Development and Service Desk to ensure the tickets are getting completed to Business satisfaction. This position will support process improvements to continuously improve the stability and performance of the mission critical applications. The Manager will also perform service transition from development to support and Identify system bottlenecks and opportunities for betterment. The Manager manages all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Manage a team of FTEs and suppliers to provide 24/7 support for Production applications across L.A. Care's Claims/EDI, Member, Provider, Health Services, Customer Solutions Business functions.</p><p>Provide technical guidance to the team in managing production incidents, -&nbsp;incident analysis, technical solution review, incident monitoring, tracking and business communications.&nbsp;</p><p>Manage Batch IT Production Control - monitoring batch jobs, addressing batch failures, and reporting metrics.</p><p>Manage Operations/maintenance activities to upkeep Production environments/functions.&nbsp;</p><p>Act as an Incident Manager and, communicate and provide coverage for significant incidents that bring down or degrade services.</p><p>Collaborate with Infrastructure team, hosted vendor teams, Release Management and Quality Assurance teams to address production incidents per the service level agreements.&nbsp;</p><p>Collaborate with Software Delivery teams to enable timely and incident-free software deployment and feature releases.</p><p>Take appropriate action to investigate and resolve incidents and problems in application systems and services. Guarantee that such incidents and problems are fully documented. Coordinate the implementation of agreed remedies and preventative measures.&nbsp;</p><p>Manage that services are met through the monitoring and achievement of critical and key performance Indicators.</p><p>Govern the delivery of service level agreement and supplier contractual obligations.</p><h4>Duties Continued</h4><p>Manage staff, including, but not limited to: hiring staff, monitoring of day to day activities of staff, monitoring of staff performance, performance reviews, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, disciplinary matters for direct reports, among others.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 4 years of leading staff or supervisory/management experience.</p><p>At least 6 years of hands-on experience with ITSM Operations, managing a 24/7 production environment.</p><p>At least 6 years of experience doing Root Cause analysis, planning of changes and managing problem tickets to full resolution in a 24x7 production environment.</p><p>Experience working with compliance, audit, outside regulators, and other support organizations while participating in providing solutions in support of the business objectives. </p><p>Experience working with off-premise hosted system/environments.&nbsp; </p><p>Hands on experience with monitoring and ticketing tools. </p><p>Experience in Incident Management, Change Management and Problem Management.</p><p>Experience in Infrastructure Support, Configuration and Release Management.</p><p>Experience in Oracle, SQL Server, DB2, Informatica, .Net, Java, MQ, Nodejs, Cassandra, splunk.</p><p>Experience on Cloud Technologies (AWS, Azure, Google), Microservices and web APIs.</p><p>Experience in Implementing Dev OPS.</p><p>Experience in leading large production support teams and Managing in a 24/7 support environment.</p><p>Experience and confidence working with all levels of management (tech and business), in a matrixed environment, acting as the central point of contact for production issues. </p><p>Experience supporting remote team members.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p><b>Required:</b></p><p>Knowledge of Unix Shell Scripting.</p><p>Basic understanding of SAFe/ Agile framework.</p><p>Advanced problem solving and analytical skills.</p><p>Effective organizational, time management and planning skills.</p><p>Excellent written and verbal skills. Able to quickly and concisely communicate with senior management on technical issues in non-technical terms and run large conf. calls with all levels and teams.</p><p>Ability to work with cross-functional teams.</p><p>Proficiency with Excel and PowerPoint and presenting to senior management.</p><p>Able to multi-task and work in a high stress environment.</p><p><b>Preferred:</b><br>HealthCare Insurance Domain expertise</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Information Technology Infrastructure Library (ITIL) Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Service Desk, Claims, Customer Service, Insurance                                                    </p>

Manager, Technology Application Production Support and Control

<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 Compliance Advisor II ensures L.A. Care business units are compliant with all Product Lines' contractual, state and federal regulatory, and accreditation requirements. The Compliance Advisor develops regulatory submissions, reports, agendas and communications to the Internal Compliance Committee and the Compliance and Quality Committee of the Board of Governors and provides support for the management of external state and federal regulatory audits. The Compliance Advisor prepares executive summaries and reports, develops and conducts training activities for subordinates, peers and L.A. Care business units and participates in interdisciplinary/cross-functional teams. </p><p>The Compliance Advisor may investigate, assist with coordination and management of teams and workgroups, project documentation and workflows, draft and complete presentations, auditing and monitoring of performance standards, and other duties as assigned. Although the Compliance Advisor's primary responsibility is providing support and for the Regulatory Compliance unit, the Advisor also advises and supports the Manager, Director, and Chief Compliance Officer on other duties as assigned to support the mission and responsibilities of the Compliance Department and to support the business operations of L.A. Care Health Plan. </p><h4>Duties</h4><p>Analyze and interpret contractual, state and federal regulatory, and accreditation requirements.</p><p>Participate in and conduct compliance functions, including, but not limited to, developing compliance tools and validating implementation of new requirements and corrective action plans.</p><p>Work with internal business units to prepare reports for distribution to internal Committees and external entities.</p><p>Facilitate cross-functional teams including internal business units and/or external entities to correct performance deficiencies.</p><p>Prepare and conduct trainings for internal business units and/or external entities.</p><p>Review, approve and suggest revisions on policies and procedures, member/provider materials, compliance work plans, etc., as well as submit to regulatory entities for approval.</p><p>Work with internal business units to identify gaps, develop and implement corrective action plans and facilitate monitoring activities to ensure compliance with regulatory requirements.&nbsp;</p><p>Review internal and external inquiries and collaborate with all levels of organizational management, business units and our Delegates to ensure timely, accurate, and complete submissions. This includes self-disclosures of non-compliance issues to the regulators.</p><p>Develop, maintain, and monitor Internal Compliance Committee (ICC) Charter, Compliance Program and&nbsp; key performance indicators. Responsible for the development of Board/committee write-ups to be presented at the Compliance &amp; Quality (C&amp;Q) and Internal Compliance Committee (ICC) meetings.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Public Health or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Health or Related Field<h4>Experience</h4><p><b>Required:</b></p><p>At least 3 years of experience in a managed care setting. </p><p>Experience in health care auditing and monitoring (preferably in Appeals, Grievances, Quality Improvement, Utilization Management (UM) and so forth) and developing audit tools.</p><p>Demonstrated experience developing and delivering training programs and making presentations.</p><p><b>Preferred:</b></p><p>2 years of Medi-Cal, Medicare or commercial product compliance. Regulatory change management and risk management experience and/or business continuity experience in a health plan or hospital setting preferred.&nbsp; </p><h4>Skills</h4><p><br><b>Required:</b><br>Excellent written and verbal communication skills.</p><p>Knowledge in health care compliance.</p><p><br>Ability to manage multiple priorities and projects and meet deadlines.&nbsp;</p><p>Knowledge of Medi-Cal Managed Care principles and/or government programs.</p><p>Persuasion Skills: 1. Ensuring organizational compliance with all state and federal Medi-Cal Program requirements reduces L.A. Care's risk to state/federal sanctions and fines- communicate required action to senior management/Board of Governor (BoG), Plan Partner staff. 2. Internal audit program and internal reviews&nbsp; are indicators of the quality of health care services provided to L.A. Care Medi-Cal members.&nbsp; This serves to help maintain a quality and solvent provider network and avert provider network disruptions due to poor quality of care and/or insolvent providers. All areas of risk/noncompliance are to be identified, reported and monitored.</p><p>Working knowledge of California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and Knox-Keene requirements, as well as highly developed analytical and critical thinking skills, to serve as a resource to internal business units and external entities.</p><p><b>Preferred:</b><br>Advanced skills in Visio, PowerPoint and/or SharePoint preferred.&nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Public Health, Internal Audit, Medicare, Medicaid, Risk Management, Healthcare, Finance                                                    </p>

Compliance Advisor 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 Customer Solution Center Appeals and Grievances Specialist I primary function is to learn the specialty level appeals and grievances work supporting the higher level position in this class series to ensure positive outcomes for members. It will support the Appeals and Grievances team to receive, investigate and resolve member and provider complaints and appeals; escalates complex issues or questions to leadership team as appropriate.</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>Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members. (20%)</p><p>Supports the identification, investigation and resolve administrative complaints, simple appeals while adhering to Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations. (20%)</p><p>Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment. (20%)</p><p>Processes assigned cases accurately and in a timely manner per instructions. Escalates complex issues or questions to leadership as appropriate. (20%)</p><p>Actively participates in team meetings and provides recommendation for improvement as appropriate based on discoveries. (10%) </p><p>Performs other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 1 year of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.</p><p>Experience working with firm deadlines, able to interpret and apply regulations.&nbsp; </p><p>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 including Word, Outlook and Excel.&nbsp;</p><p>Ability to provide confidentiality and professional customer service skills.&nbsp;</p><p>Ability to work under tight deadline.</p><p>Strong analytical, verbal, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.&nbsp;</p><p>Knowledge of Medical terminology.</p><p><b>Preferred:</b><br>In depth knowledge of DHCS, NCQA, CMS, DMHC regulartories and guidelines.</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>                    Medicare, Medicaid, Healthcare                                                    </p>

Customer Solution Center Appeals and Grievances Specialist I

<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 Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope.</p><p>This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership.</p><p>The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff.&nbsp; The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Ensures adequate/appropriate distributions of workforce, assignments and time off requests. &nbsp;Participates in the hiring and termination process providing recommendations with appropriate supporting documentation.</p><p>Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. &nbsp;Identifies, communicates and coaches to improve staff performance. &nbsp;Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. &nbsp;Completes intermittent and annual staff evaluations.</p><p>Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary.</p><p>Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals.</p><p>Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members.</p><p>Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department.</p><p>Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. &nbsp;Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. &nbsp;<br><br>Serves as a leader and role model as well as technical and informational resource for staff and peers.</p><h4>Duties Continued</h4><p>Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes.</p><p>Services as member/resource/liaison to the Interdisciplinary Care Team. &nbsp;</p><p>Recommends resources to improve performance standards in terms of Utilization Management. &nbsp;Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.</p><p>Participates on internal and external committees as delegated or assigned.</p><p>Serves as a consultant to other departments or organizations as needed.</p><p>Responsible for the daily workflow and leading the work of assigned staff.&nbsp; This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff.</p><p>Performs other duties as assigned.</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><br>Minimum of 7 years of acute/clinical care experience.<br></p><p>Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. </p><p>Minimum of 3 years leading process, program, or staff or supervisory experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p><b>Required:</b><br>Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management.</p><p>Strong verbal and written communication skills.</p><p>Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.</p><p>Excellent organizational, time management, and interpersonal skills.</p><p>Must be detailed-oriented, energetic, and an enthusiastic team player.</p><p>Must be able to work independently.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><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, Healthcare                                                    </p>

Supervisor, Utilization Management RN

<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 Delegation Oversight Compliance Auditor III is responsible for planning, coordination, and conducting comprehensive compliance audits and reviews to assess adherence to regulatory requirements, contractual obligations, and internal policies for L.A. Care subcontracted providers.&nbsp; Additionally, the Auditor III will provide updates and recommendations to Management on quality and delegation oversight responsibilities, participate in fraud, waste, and abuse investigations as applicable, and oversee pre-delegation and annual audits for new and existing delegated entities to drive continuous improvement and adherence to regulatory standards by ensuring delegates are compliant with regulatory requirements. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.</p><h4>Duties</h4><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><b>Regulatory:</b></p><p>Researches, analyzes, and interprets contractual, state, and federal regulatory, and accreditation requirements. Stays abreast of changes in healthcare regulations, laws, and industry standards; analyzes regulatory developments and assesses their impact on the organization. Updates existing audit tools and creates audit tools based on the regulatory requirements. Assists management team with informing team of regulatory changes to ensure alignment with regulatory requirements and industry best practices.</p><p><b>Audit:</b></p><p>Plans, coordinates, and conduct with other auditors and conducts comprehensive compliance audits and reviews to assess adherence to regulatory requirements, contractual obligations, and internal policies for L.A. Care subcontracted providers including, but not limited to, Participating Physician Groups, Plan Partners, and Specialty Health Plans/Vendors. Independently conducts complex audits, including scoping, research, tool development, field work, reporting, and corrective action plan validation. Identifies, documents, and trends audit issues and provides appropriate coaching and shares best practices with delegated entities to assist with performance improvement. </p><p><b>Investigate and Risk Assessment:</b></p><p>Investigates and escalates allegations of non-compliance, fraud, or misconduct; develops and implements corrective action plans to address identified issues and prevent recurrence. Conducts risk assessments to identify compliance risks and develops strategies to mitigate risks and strengthens internal controls. Alerts management of identified new or emerging compliance risks and makes recommendations on DOA’s audit plan or monitoring plan to other business unit. Serves as a subject matter expert in compliance auditing, risk assessment, risk mitigation planning and regulatory interpretation and application. </p><h4>Duties Continued</h4><p><b>Collaboration:</b></p><p>Leads entrance calls, exit conferences, and technical calls with delegates. Collaborates with cross-functional teams, including but not limited to Legal, Compliance, Quality Assurance to address compliance-related challenges and delegate’s performance deficiencies, and implement effective solutions. Assists management to establish processes to track program effectiveness; monitor and analyze data to identify trends and areas for improvement. Works closely with Delegation Oversight Audit management on and to co-lead projects.</p><p><b>Reports:</b></p><p>Prepares and presents comprehensive reports and presentations to senior leadership, internal Committees, external entities, summarizing compliance activities, findings, and recommendations. Reviews and provides feedback on work papers of other Auditors to ensure accurate testing, results, and reports, and to ensure adherence to departmental procedures and protocols.</p><p><b>Training:</b></p><p>Develops and delivers compliance training programs for internal staff members, such as Delegation Oversight Audit team, and other business units within L.A. Care. In addition, to develop training programs for delegates as external entities ensuring awareness of compliance requirements and promoting a culture of compliance throughout the organization and with delegates. Leads and manages compliance projects and initiatives, auditors’ trainings. Develops training materials, updates audit tools, performs risk assessments, policy development, and process improvement efforts. </p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Healthcare Administration 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 4 years of audit experience in compliance, delegation oversight, or audit within the healthcare industry.</p><p>Demonstrated experience developing and delivering training programs and making presentations to internal staff and providers.</p><p>Experience in health care service plans with significant delegation arrangements. </p><p>Experience working with Policies and Procedures.</p><h4>Skills</h4><p><b>Required:</b></p><p>Ability to manage multiple priorities, projects and meet deadlines.</p><p>Superior written and verbal communication skills.</p><p>&nbsp;Ability to draft policies and procedures. </p><p>Exceptional analytical and problem-solving skills, with a meticulous attention to detail.</p><p>Strong communication and collaboration abilities, with the capacity to engage effectively with stakeholders at all levels.</p><p>Ability to create a work environment that fosters team building and encourages a collaborative approach to achieving departmental and organizational goals.</p><p>Proficient in Microsoft Office, Excel, and PowerPoint.</p><p>In-depth knowledge of federal and state laws, Medicaid regulations, and healthcare compliance standards.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified HealthCare Compliance (CHC)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Healthcare Administration, Medicaid, Audit, Healthcare, Finance                                                    </p>

Delegation Oversight Compliance Auditor III

<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 Enhanced Care Management (EMC) Justice-Involved Specialist II responsible for the design and implementation of strategies to support justice-involved members at L.A. Care, ensuring alignment with the CalAIM Justice-Involved (JI) initiative. &nbsp;As the primary contact for correctional facilities, EMC providers, and state and county partners, this position fosters collaboration, drives systemic improvements, and ensures compliance with regulatory and service standards.</p><h4>Duties</h4><p><b>Primary Point of Contact: </b>Serve as the primary L.A. Care liaison with correctional facilities, ECM providers, and state and county entities such as the Department of Health Care Services (DHCS), LA County Sheriff’s Department, Department of Mental Health (DMH) and Department of Public Health (DPH) ensuring alignment with regulatory standards and facilitating care transitions for justice-involved members.</p><p><b>Guidance and Support for ECM Providers: </b>Develop and implement guidance for ECM providers, ensuring they effectively navigate justice-involved coordination protocols and meet DHCS standards for serving this population.</p><p><b>Relationship Building and Stakeholder Engagement: </b>Drive stakeholder engagement by cultivating strong, collaborative relationships with correctional, mental health, and social service agencies. Build partnerships to streamline services and improve outcomes for justice-involved members.</p><p><b>Specialist in Justice-Involved Populations:</b> Act as a thought leader and knowledge resource on justice-involved populations, including pre-release and post-release requirements, Medi-Cal eligibility and benefits, provider services, and considerations for sub-populations such as children and youth.</p><p><b>Systemic Barriers and Issues Resolution:</b> Proactively identify systemic barriers impacting justice-involved members’ access to care. Design and implement solutions to address overlaps, resolve conflicts, and improve coordination between stakeholders.</p><p><b>Compliance and Program Alignment: </b>Ensure that processes and documentation align with CalAIM JI requirements, supporting effective reporting, data sharing, and adherence to county and state agreements.</p><p><b>Training and Best Practices: </b>Coordinate training initiatives for ECM providers and partners on justice-involved protocols, ensuring the adoption of best practices and trauma-informed approaches to care.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Social Work or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Social Work or Related Field<h4>Experience</h4><p><b>Required:</b></p><p>At least 3 years working with justice-involved populations, focusing on reentry services, case management, or community health programs. </p><p><b>Preferred:</b></p><p>Justice Involved lived experience.&nbsp; </p><h4>Skills</h4><p><b>Required:</b></p><p>Strong collaboration and relationship management skills with justice and healthcare entities.</p><p>Excellent verbal and written communication skills.</p><p>Detail oriented, organized and possess time management skills.</p><p>Basic computer skills.</p><p>Microsoft Office (Word, Excel, Power Point, Access, and Visio).</p><p><b>Preferred:</b></p><p>Understanding of Medi-Cal benefits, ECM and the California Advancing and Innovating Medi-Cal (CalAIM) Justice-Involved initiatives.</p><p>Knowledge of L.A. Care core computer system.</p><p>Motivational Interviewing skills.</p><p>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&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>Motivational Interviewing Certification<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><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, Relationship Manager, Counseling, Public Health, Service, Customer Service, Healthcare                                                    </p>

47 L.A. Care Health Plan Jobs