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<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>

L.A. Care Health Plan

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>Manager, Financial Compliance Audit (Finance) has a $10,000 SIGN-ON BONUS.&nbsp; This role is responsible for the timely and quality delivery of a variety of complex areas across all lines of business, including Medi-Cal, Covered California, D-SNP, and PASC-SEIU. This position manages the financial audit team in ensuring the delegates such as plan partners, participating provider groups (PPGs), and capitated hospitals, Specialty Health Plans, and vendors contracted with L.A. Care adhere to contractual agreements, applicable laws &amp; regulations, policies, and industry standards which provide medical, hospital, vision, dental, behavioral health, transportation and telehealth services. &nbsp;This position is responsible for planning, executing, reporting, and monitoring financial solvency audits and ensuring meeting the audit calendar and reporting requirements.&nbsp; This position manages the quarterly/annual financial analysis to ensure that delegates are financially solvent.&nbsp; The Manager monitors the plan partners' oversight activities of their Medi-Cal provider network.&nbsp; Manages all aspects of running an efficient and high-performance team, including hiring, supervising, coaching, training, annual performance reviews, disciplining, and motivating direct reports. </p><h4>Duties</h4><p>Manages all financial solvency related audits and related monitoring activities independently in accordance with general accepted auditing standards, generally accepted accounting principles (GAAP), regulations of the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and other federal and state guidelines.</p><p>Responsible for the oversight of all aspects of financial solvency reviews including, but not limited to, the planning, execution, continuous monitoring, and reporting of annual financial audits, quarterly and annual financial analyses (ratio and trending analyses), and special projects.</p><p>Manages staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</p><p>Manages and ensures timely and accurate review of deliverables.&nbsp; Ensures financial solvency compliance with regulatory and contractual requirements for plan partners, PPGs, capitated hospitals, specialty health plans, and vendors.</p><p>Manages the design, implementation, and reporting of special projects such as Medical Loss Ratio.</p><p>Manages the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.</p><p>Manages the assessment, communication, implementation of regulatory requirements that may impact internal processes.&nbsp; Responsible for the on-going communication, collaboration, and issue resolution on financial solvency issues with interdepartmental personnel, key stakeholders, and delegates.</p><p>Manages the formalization of key internal processes and monitoring tools with desktop procedures and applicable policies and procedures development.</p><p>Responsible for the completion and review of financial audit team’s pre-delegation assessment and delivery of &nbsp;monthly/quarterly request updates to various business units.</p><h4>Duties Continued</h4><p>Responsible for the overall communication and collaboration with cross-functional teams, senior leadership, and delegates.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.&nbsp; </p><p>Oversees the monitoring and analysis of membership data by delegates on a monthly basis to assign the annual claim processing and financial solvency audits, adherence to regulatory requirements.</p><p>Manages complex financial solvency audits to ensure quality deliverables, resolve audit issues, and issuance of final audit reports.&nbsp; Requests and follow-ups on Corrective Action Plans (CAPs) on non-compliant audit results.</p><p>Develops, implements, and executes the audit program and audit procedures for updates and/or changes in the agreement and applicable regulations.</p><p>Oversees and reviews the comprehensive financial analysis on a quarterly and annual basis to ensure Plan Partner (PPs), Participating Physician Groups (PPGs), and capitated hospitals, Specialty Health Plans, and vendors comply with the financial solvency requirements.&nbsp; Requests and follow-ups on CAP for non-compliant issues.</p><p>Monitors the plan partners' audit and quarterly financial analysis of their Medi-Cal provider network.</p><p>Communicates effectively with senior leadership on compliance matters from audits or quarterly financial statements analysis including recommendations and corrective action plans requirements.</p><p>Maintains related company's policies and procedures ensuring they are current.</p><p>Proactively identifies opportunities and solutions to improve the effectiveness and efficiency of the financial audit function.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Finance or Accounting or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 6 years of experience in financial auditing in a managed care industry.</p><p>At least 4 years of leading, supervising and/ or managing staff experience.&nbsp; </p><p>Proven experience in leading and managing audit teams.</p><p>Significant experience in assessing, investigating, and auditing compliance risks.</p><p><b>Equivalency:&nbsp; </b></p><p>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>Demonstrated ability to handle the growing population in the L.A. Care network and audit activities.</p><p>Excellent verbal and written communication, and presentation skills.</p><p>Knowledge of relevant managed care regulations and audit methodologies.</p><p>Excellent analytical and problem-solving skills.</p><p>Ability to interface professionally with both internal and external customers at all levels of the organization.</p><p>Must be self-motivated, detail-oriented, prioritize assignments, and able to work as part of a team.&nbsp; </p><p>Knowledge of and ability to oversee the major responsibilities, accountabilities, and organization of the audit and compliance function.</p><p>Knowledge of and ability to create, implement, evaluate and enhance internal control processes.</p><p>Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).</p><h4>Licenses/Certifications Required</h4>And/Or any of the following Licenses/ Certifications:Certified Public Accountant (CPA)Certified Internal Auditor (CIA)Certified Management Accountant (CMA)Certified Fraud Examiner (CFE)<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>                    Accounting, CPA, Internal Audit, Behavioral Health, Audit, Finance, Healthcare                                                    </p>

Manager, Financial Compliance Audit, $10,000 SIGN ON BONUS

<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>The Customer Solution Center (CSC) Representative II has advanced knowledge of healthcare and various managed care product lines, including Medi-Cal, PASC, L.A. Care Covered/Cal Medi-Connect and is proficient in medical terminology. The position responsibilities include duties such as: assist supporting queues and management with projects as needed (e.g. provide informative feedback on desktop procedures, follow-up on member inquiries, CSC Representative shadowing etc.), acting as back-up support to Call Center Leads. This position handles inbound and outbound interactions involving member eligibility verification, general provider inquiries, claim status (pre-payment), &nbsp;general program and administration questions for all lines of business including direct member request for I.D cards and Primary Care Physician (PCP) changes, triages calls to appropriate units or outside entities and processes payments for L.A. Care Covered members. All interactions are documented in system of record.</p><h4>Duties</h4><p><br>Answers incoming calls for all product lines 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 systems. (QMEIS). 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. (60%)</p><p>Processes payments for L.A. Care Covered members. (15%)&nbsp;</p><p>Supports robocall and ad-hoc member outreach activities as determined by business need. (15%)</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><h4>Experience</h4><p><b>Required:</b></p><p>At least 1 year of customer service call center experience in a healthcare environment. </p><p>Data entry experience with ability to type a minimum of 40 wpm. </p><p><b>Preferred:&nbsp; </b></p><p>Managed care or health plan experience.</p><p>Previous Automatic Call Distribution (ACD) experience preferred. </p><h4>Skills</h4><p><b>Required:</b></p><p>Knowledge of medical terminology.</p><p>Good understanding of service to the disadvantaged population, seniors and or people with chronic conditions or disabilities. </p><p>Must be a quick learner, excellent team player and customer service oriented. </p><p>Ability to answer a high volume of calls.</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><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 II

<p><b>Salary Range:&nbsp;&nbsp;<b><b><b><b>$47,840.00</b></b></b></b>&nbsp;(Min.) -&nbsp;<b><b><b><b>$57,062.00</b></b></b></b>&nbsp;(Mid.) -&nbsp;<b><b><b><b>$68,474.00</b></b></b></b>&nbsp;(Max.)</b></p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</p><p>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</p><p>In addition, the position performs data entry and processing of referrals/authorizations in the system, &nbsp;authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</p><h4>Duties</h4><h4>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure&nbsp; all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</h4><h4>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</h4><h4>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</h4><h4>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</h4><p>Perform other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b></p><p>At least 6 months of health care experience.</p><p>Experience working in a cross functional work environment.</p><p><b>Preferred:</b></p><p>Experience in Medi-Cal managed care.</p><p>1 year of experience in UM/Prior Authorization.</p><h4>Skills</h4><p><b>Required:</b></p><p>Demonstrated proficiency in Medical Terminology required.</p><p>Strong verbal and written office communication skills.</p><p>Proficient with Microsoft Office Suite and Adobe PDF. and </p><p>Excellent organizational, interpersonal and time management skills. </p><p>Must be detail-oriented and an enthusiastic team player.</p><p><b>Preferred:</b></p><p>Knowledge of QNXT computer systems a plus.</p><p>Knowledge of the UM patient referral process.</p><p>Knowledge of member’s health plan eligibility.</p><p>Knowledge of member’s benefits coverage. </p><p>Knowledge of Health Plan regulations.</p><p>Knowledge of HMO/UM functions.</p><p>Knowledge of ICD-10/CPT coding. </p><p>Proficient utilizing electronic medical records and documentation programs.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Medical Coding Certification<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Required:</b></p><p>Weekends and holidays hours may be required, as well as OT based on a business need.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.</p><p><br><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    EMR, Data Entry, Medical Coding, Claims, Healthcare, Administrative, Insurance                                                    </p>

Authorization Technician II (12 Month Assignment)

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager of Information Technology (I.T.) Business Intelligence is responsible for leading the team that designs, delivers, integrates and supports core management applications and interfacing systems. This position will identify, evaluate &amp; implement new business analysis tools. This position will enable and develop new business analytic capabilities and proficiencies by partnering with the Business Partners/ stakeholders to understand needs and innovate solutions. With an understanding of the organization’s business and knowledge of the various technological capabilities/platforms, the Senior Manager will advise key stakeholders on an array of possible technical solutions, effectively communicating advantages, disadvantages and potential risks of different approaches. This position will also develop and motivate highly technical teams to accomplish these goals. &nbsp;This position manages all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.&nbsp;</p><h4>Duties</h4><p>Directs and facilitates application development and support activities, managing multiple interrelated projects concurrently, daily applications' and configuration support operations. Ensures effective collaboration with Information Technology (I.T.) Leadership so that all I.T. processes are maintained and enhanced in support of the mission and goals.</p><p>Maintains staff by recruiting, selecting, orienting, and training employees; maintaining a safe, secure, and legal work environment; developing personal growth opportunities. &nbsp;Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and disciplining employees; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards. Manage teams balance workload, appraisals, and objective setting. Ensures appropriate staffing and budget and allocation of all resources so that all I.T. initiatives and work products can be accomplished. Ensures adherence to policy for subordinate staff within I.T.</p><p>Develops and implements the strategy, action plans and projects focused on next generation tools &amp; techniques. Provide thought equity to identify new and innovative business analysis tools and techniques in response to business needs. Collaborate with developers and subject matter experts to establish the technical vision and analyze tradeoffs between usability, cost and performance. Ensures that all business critical systems and applications are operational and meet established service agreements with business customers.</p><p>Develop new business analytic capabilities and proficiencies. Design and develop insightful analysis including those focused on historical trend analysis with an understanding of key drivers. Evaluate and leverage new analytical tools and techniques.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business Administration or Information TechnologyIn 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 direct/relevant experience in identifying, evaluating and implementing new technology solutions.</p><p>At least 4 years leading staff or supervisorial/management experience.</p><p>Experience in evaluating and leveraging different business analysis techniques.</p><h4>Skills</h4><p><b>Required:</b><br>Must be well organized, flexible, motivated and enjoy the challenges of supporting a growing team.&nbsp;</p><p>Demonstrated ability to build relationships with the individual business units, our customers, and their team to ensure that the services provided are of exceptional quality.</p><p>Ability to interact with staff at all levels across multiple businesses in a fast paced environment, sometimes under pressure, remaining flexible, proactive, resourceful and efficient, is crucial to this role.&nbsp;</p><p>Strong written and verbal communication skills.</p><p>Strong decision making ability and attention to detail.&nbsp;</p><p>Familiar with the System Development Life Cycle process and be able to manage relationships at the various hand-off points in the cycle.</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>                    Equity, Finance                                                    </p>

Senior Manager, Information Technology Business Intelligence

<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 Customer Solution Center (CSC) Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for the following end-to-end processes within CSC (i.e. Enrollment processing timeliness and accuracy of loading members, timeliness of I.D. Card and member materials, outbound health risk assessment (HRA) calls for Seniors and People with Disabilities (SPD) and Cal MediConnect (CMC) plus HIF for L.A. Care Medi-Cal Direct program (MCLA), call documentation and categorization, service authorization request and coverage determination , Appeals and Grievances across all lines of business). This position is responsible for the ongoing progression and maintenance of CSC's compliance program efforts, including, but not limited to, policy and procedure development, training and education initiatives, and compliance programmatic developments and enhancements.</p><p>This position will complete targeted, focused and random audits related to member interactions and outcomes to ensure all elements are compliant. These results will be provided to management with recommendations and/or corrective actions required to remediate the deficiencies. This position will be responsible for the regulatory obligations for each line of business and their governing bodies; California Department of Health Care Services (DHCS), Department of Public Social Services (DPSS), Centers for Medicare and Medicaid Services(CMS), LACC - CalHers, and National Committee for Quality Assurance (NCQA) along with review and analysis of regulatory requirements for all product lines The position will take lead in all of the audit situations and be prepared to present and report full findings and ensure action plans are created, executed, and verified through reconciliation of end to end on all regulatory functions. &nbsp;&nbsp;</p><h4>Duties</h4><p>Audit readiness: Performs audit procedures for Customer Solution Center departments to ensure readiness; including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting business unit processes and procedures. Conducts interviews, reviews documents, develops and administers surveys, composes summary memos and prepares working papers. Identifies, develops, and documents audit issues and recommendations using independent judgement concerning areas being reviewed. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to Customer Solution Center management. Collaborates with business units in audit universe preparation and validation. Assists in document preparation for regulatory and internal audits.<br><br>Regulatory compliance: Works closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes. Collaborates with internal Subject Matter Experts (SMEs) to understand Customer Solution Center regulatory processes and assists with getting to the root cause of identified deficiencies. Evaluates policies and procedures with applicable regulations/guidelines and provides recommendations to management for continuous process improvements. &nbsp; &nbsp; &nbsp; &nbsp;</p><p>Collaborates with Customer Solution Center Business Analyst to track, trend, and analyze results of Quality Assurance (QA) scorecards for training and quality improvement. &nbsp;</p><p>Perform other duties as assigned.&nbsp;</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>A minimum of 5 years of experience in regulatory auditing (Appeals &amp; Grievances, Call Center, Enrollment) in a healthcare environment required. </p><p>Previous experience with Medi-Cal and Medicare in a managed care environment. </p><p><b>Preferred:&nbsp; </b></p><p>Tableau experience.</p><h4>Skills</h4><p><b>Required:</b><br>Advanced computer proficiency, Word, Excel; and Access is required.&nbsp;</p><p>Strong analytical and team building skills.&nbsp;</p><p>Ability to work effectively with diverse team members.&nbsp;</p><p>Ability to formulate recommendations to improve quality and service delivery, and develop effective system and process improvements.&nbsp;</p><p>Ability to multi-task and streamline day-to-day operations.&nbsp;</p><p>Ability to track and trend and create regulatory reporting.</p><p>Strong interpersonal and organization skills and is expected to work independently within the department's established guidelines, policies and procedures.&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>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, Social Services, Medicaid, Call Center, Audit, Healthcare, Service, Customer Service, Finance                                                    </p>

Customer Solution Center Audit Readiness Specialist II

<p><b>Salary Range:&nbsp;</b>&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Systems Administrator II is responsible for day-to-day tasks and projects relating to the various operating systems, i.e. Windows 2008-12, Linux. This position works closely with System Administrators, DBAs, and Application groups in solving problems, and is responsible for managing business critical servers, and NetApp and Network Appliance Storage and subsystems, for a variety of applications in 99.9% up-time configurations. Ensure systems are performing at peak levels; implement tools to monitor system performance. Provide regular maintenance for Unix OS(s), MS-Windows, VMware, and Pick/Universe databases; routine administration, upgrades, design implementation, and documentation support.&nbsp;</p><h4>Duties</h4><p>Install, maintain, and upgrade software and O/S on EMC and Net-App devices, Tivoli Storage Manager and Net Backup.</p><p>Perform storage analysis, UNIX tuning, and Pick/Universe tuning functions on a regular basis.&nbsp;</p><p>Provide project plans to support seamless implementations. Organize work sessions with support groups to ensure well-planned implementations.</p><p>Develop and maintain security access levels for UNIX and windows servers systems.</p><p>Develop and maintain standards for all UNIX systems and windows systems.&nbsp;</p><p>Design and implement a disaster recovery plan for the core UNIX systems.</p><p>Perform other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Information Systems or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p><b>Required:</b></p><p>At least 3 years of experience in managing large scale computing environment running multiple platforms (RS/6000 AIX 5.2, LINUX Apache/Tomcat), Vmware vSphere 5.1 - 5.5.&nbsp; </p><p>Experience in development and implementation of Integration solutions for business application across multiple platforms on Windows, UNIX O/S and Linux environments.</p><h4>Skills</h4><p><b>Required:</b></p><p>Knowledge of Windows servers, VMware,&nbsp;HP servers, Email Secure File Transfer, file share, and VDI.</p><p><b>Preferred:</b></p><p>Knowledge of Tivoli Storage Manager, EMC Subsystems (TimeFinder, Powerpath, BCV), IBM LTO. </p><p>Ability in Scripting (PowerShell), backup, and cloud (Azure and AWS).</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>

Systems Administrator II

<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p><br>The Internal Auditor III prepares audit programs and conducts audit reviews of assigned areas, including performing various audit procedures and documents in findings in work papers in accordance with department standards. Identifies internal control weaknesses, develops audit recommendations and drafts written reports. Provides independent evaluations of operational and financial controls, policies, and procedures. Prepares audit report detailing findings and recommendations. Performs and coordinates follow-up audits to determine if management has taken action to mitigate risks identified. Participates in special reviews as necessary.Acts as a &nbsp;Subject Matter Expert, serves as a resource and mentor for other staff.&nbsp;</p><h4>Duties</h4><p>Develops audit programs and testing procedures relevant to risk and test objectives. Provides independent evaluations of operational and financial controls, regulatory compliance, policies, and procedures. Prepares work papers, observations and reports and related documents following department standards.</p><p>Prepares audit programs and conducts audit reviews of assigned areas, including performing various audit procedures and documenting findings on work papers. Obtains and reviews evidence ensuring audit conclusions are well-documented. </p><p>Identifies internal control weaknesses, non-adherence with regulatory requirements, develops audit recommendations and drafts written reports. Identifies and communicates issues raised, offering recommended solutions relevant to business and risk. Ensures audit conclusions are based on a complete understanding of the process, circumstances, and risk. </p><p>Performs and coordinates follow-up audits to determine if management has taken action to mitigate risks and findings identified.</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>Participates in special reviews as necessary.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Accounting or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><strong>Required:</strong><br>At least 5 years of public or private accounting or audit experience, preferably in health care or other highly regulated industry.</p><h4>Skills</h4><p><br><b>Required:</b><br>Knowledge of finance, accounting and control principles, including GAAP and GAAS.</p><p>Excellent MS Office skills, including in Word, Excel and PowerPoint.</p><p>Ability to observe and understand business processes ensuring processes are documented completely and accurately.</p><p>Ability to apply audit standards through practical application.</p><p>Proactive in researching business best practice concepts in order to apply as appropriate.</p><p>Solid listening skills and ability to identify gaps in logic – inquisitive.</p><p>Strong organization and follow up skills including the ability to handle competing priorities and meet all deadlines and commitments.</p><p>Possess an appropriate combination of technical expertise in fields such as auditing, finance, technology, operations, or investigations.</p><p>Ability to flourish in a fast-paced, complex environment and willing to adapt to change.</p><p>Ability to give and follow instructions accurately and efficiently; proactive in asking clarifying questions to ensure work effort is directed wholly toward desired outcome.</p><p>Ability to recognize when learned theoretical concepts should be applied.</p><p>Solid understanding and ability to apply risk and control concepts</p><p>Ability to identify underlying cause of an issue raised.</p><p>Good awareness of other departments in the company with risk, control, and governance responsibilities and what is necessary for successful tactical collaboration and information sharing.</p><p>Good communication skills along with good or developing negotiation skills.</p><p>Ability to identify sensitive issues and facilitate communications in a proactive manner to avoid surprises.</p><p>Willingness and ability to adapt to new circumstances, information, and challenges.</p><p>Executes effective and thorough application of all internal audit standards within assigned responsibility.</p><p><b>Preferred:</b><br>Knowledge of Sarbanes-Oxley and COSO guidelines and requirements.</p><p>Risk assessment practices.</p><h4>Licenses/Certifications Required</h4>Certified Public Account (CPA) or Certified Internal Auditor (CIA) or Cerfitified Fraud Examiner (CFE) or Certified Information Systems Auditor (CISA)<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>                    Internal Audit, Risk Management, Accounting, CPA, Audit, Finance                                                    </p>

Internal Auditor III

<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Enterprise Risk Adjustment Analyst III provides a key leadership role in the Risk Adjustment Department by independently determining and recommending the source/type of data to be used, design/method in which to create reports or conduct analysis to address business objectives, and recommendations for course of action.&nbsp; </p><p>This position works in collaboration with the Enterprise Risk Adjustment department leadership and provides leadership/guidance in matters related to data processing, data storage, and data architecture. The position provides guidance and direction to the analyst, internal and external stakeholders with regards to reporting and analytics.</p><p>Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Serves as Subject Matter Expert (SME) for the data processing, reporting, and analytics required to support the Risk Adjustment department operations Chief Architect for reporting and analytics in support of Risk Adjustment operations for multiple lines of businesses. Serves as key contact for both internal (L.A. Care) and external (Vendors, regulatory agencies, etc.) requestors for Risk Adjustment data and reporting. Works with the risk adjustment vendors and keeps up to date on the latest risk adjustment changes that regulatory bodies pass on to health plans as it relates to reimbursement reporting requirements. Brings identified concerns to the Manager with recommendations for resolution.</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>Creates and produces summary reporting artifacts to give the Risk Adjustment Department the ability to monitor its performance. Provides guidance and direction to the analyst, internal and external stakeholders with regards to reporting and analytics. Conducts and provides analytical insight to gaps in performance.&nbsp; </p><p>Continuously monitors and reviews the daily operations to identify areas of improvement and for automation process. Designs and creates processes for data extraction, summaries, and higher level analytic functions to create and use on data queries and stored procedures. Creates and maintains database for the Risk Adjustment team to improve the workflow in various operational areas of risk adjustment.</p><p>Understands the end to end requirements for XML and 837 data processing channels to provide impact analyses from regulatory changes to these processes, and data reconciliation gaps.</p><p>Performs 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><strong>Required:</strong><br>At least 5 years of experience working in a risk adjustment role with increasing responsibilities and working with data submitted to regulatory agencies, and the return reports received from same.</p><h4>Skills</h4><p><b>Required:</b><br>Ability to consult with senior management help define business objectives and recommend analysis approach to address these objectives.</p><p>Ability to provide expertise on analytic, programmatic, and process changes that is a response to changing business needs.</p><p>Ability to query from various internal databases and external vendors systems in order to write/build/develop needed data to perform higher level of analytics to address business objectives. Provide recommendations to senior leadership based on analytics outcome.</p><p>Knowledge of risk adjustment processes for multiple lines of business.</p><p>Reporting and analytics experience of SQL Server, Visual Studio 2012, Oracle, Microsoft Access and Excel.</p><p>Knowledge of MS Word, Adobe Reader, PowerPoint programs.</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>                    Risk Management, Finance                                                    </p>

Enterprise Risk Adjustment Analyst 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 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>

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