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<p>Salary Range:&nbsp;&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 Appeals and Grievances Clinical Operations (A&amp;G) RN is responsible for executing the day-to-day clinical operations of the A&amp;G department, and monitoring the A&amp;G RN staff responsibilities and activities. This includes, but is 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 resolutions within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Appeals &amp; Grievances 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 for assisting with and development and maintenance of a successful and cohesive unit, with a high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the A&amp;G 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 A&amp;G Clinical Manager. This role also assists the A&amp;G Leadership 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 A&amp;G 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 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 A&amp;G team. 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 A&amp;G clinical activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members.</p><h4>Duties Continued</h4><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; </p><p>Serves as a leader and role model as well as technical and informational resource for staff and peers.</p><h4>Fosters a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes.</h4><h4>Serves as a member/resource/liaison to the A&amp;G Operations Team.</h4><h4>Recommends resources to improve performance standards in terms of Appeals &amp; Grievances.&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.</h4><h4>Participates on internal and external committees as delegated or assigned.</h4><h4>Serves as a consultant to other departments or organizations as needed.</h4><h4>Performs other duties as assigned.</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p>Required:</p><p>Minimum of 8 years of acute/clinical care experience.</p><p>Minimum of 2 years of experience in RN clinical operations in an acute care or health plan setting.</p><p>Minimum of 2 years in a lead/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>Required:</p><p>Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality.</p><p>Strong verbal and written communication skills.</p><p>Computer literacy with proficiency in 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>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>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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, Clinical Research, Medical Research, Clinic, Healthcare                                                    </p>

L.A. Care Health Plan

Supervisor, Appeals and Grievances Clinical Operations RN

<p>Salary Range:&nbsp;&nbsp;$50,216.00&nbsp;(Min.) -&nbsp;$62,770.00&nbsp;(Mid.) -&nbsp;$75,324.00&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 (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>Required:<br>At least 1 year of customer service call center experience in a healthcare environment.&nbsp;</p><p>Data entry experience with ability to type a minimum of 40 wpm.&nbsp;</p><p>Ability to answer a high volume of calls; previous ACD experience preferred.&nbsp;</p><p>Preferred: &nbsp;<br>Managed care or health plan experience.</p><h4>Skills</h4><p>Required:<br>Knowledge of medical terminology.</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.&nbsp;</p><p>Preferred:<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>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Customer Solution Center Service Representative II

<p>Salary Range:&nbsp;&nbsp;$47,840.00&nbsp;(Min.) -&nbsp;$57,062.00&nbsp;(Mid.) -&nbsp;$68,474.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Performance Management Coordinator II provides a broad range of coordination and operational support to the Audit Services Department. The position is mainly responsible for maintaining, monitoring and tracking reporting for Internal Audit and contracted Provider Groups and Specialty Health Plans. This includes the maintenance of the monthly, quarterly, and annual reporting activities; monitors and tracks the reporting for timeliness and completeness.</p><h4>Duties</h4><p>Prepares internal audit and delegate reports and tracking logs; assists in providing data to support monthly trend reports for the various Committees and Delegation Oversight Workgroups. Produces internal audit and delegation activity reports in a timely manner for use in the Committee meetings. Coordinates exchange of delegate's reports from the appropriate internal departments for use in risk ranking delegated Provider Group/Specialty Health Plan. Completes data entry into department reports and trackers, and ensures data entry accuracy through review and cross-referencing. (30%)</p><p>Demonstrates ability to coordinate, prioritize and execute the following task: monitors submission of internal audit and delegate reports, provides tracking alerts for late or missing information, coordinates and schedules meetings with applicable internal business units and delegates, coordinates reviews of audit documents and reports (25%)</p><p>Coordinates and communicates with all internal business units and contracted participating physician groups (PPGs) via email and telephonically for task vital to the Audit Services Department. (20%)</p><p>Actively identifies and makes recommendations on areas for improvement of effectiveness and efficiencies of department functions. (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>Required:<br>At least 6 months of coordination/operation support in a health plan or health care related field.</p><h4>Skills</h4><p><strong>Required:</strong><br>Advanced proficiency in Microsoft Office applications.</p><p>Ability to work independently, prioritize workloads and handling multiple assignments.</p><p>Strong interpersonal and communication skills required to interface with a wide variety of internal and external stakeholders.</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>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Performance Management Coordinator II

<p>Salary Range:&nbsp;&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><br>The Lead of Customer Solution Center Appeals and Grievances is responsible for assisting with the development of a successful and cohesive Appeals and Grievance unit, with a high level of productivity to achieve the department's overall performance metrics, and to meet and/or exceed member satisfaction. Responsible for the day to day oversight of Appeals and Grievance Specialist by closely monitoring work, providing feedback on performance, trains, coaching, mentoring, motivating, and ensures compliance to policies, procedures and regulations. Ensures that all Appeals and Grievances are processed accurately and timely.&nbsp;</p><h4>Duties</h4><p>Leads day to day activities of the Appeals and Grievances team including but not limited to: Providing direction to the team, handling internal or external questions or issues raised in relation to Appeals or Grievances and recommending and implementing resolution, new processes and or process improvement. Assist Supervisor to ensure that Specialist provide accurate, timely, and quality responses. Ensure that all departmental policies, procedures and standards are being followed in an effort to meet departmental and organizational goals. Assist the Supervisors to ensure that deviations in performance are identified in advance and process changes are made to redirect performance to acceptable levels. Provides accurate and timely written and/or verbal statistical reports that includes historical and/or current data to aid in projecting or evaluating Compliance status. Assist Supervisor in reviewing the Specialists overall quality and accuracy, provide education and training where applicable to remediate reoccurrences. Support and lead the distribution and redistribution of inventory and/or assignments as needed. Ability to accurately process all case types including regulatory cases and to provide recommendations towards resolution.</p><p>Trains and motivates staff. Ensures appropriate compliance standards are followed and maintained. Work closely with Supervisors to create and/or modify Desk Level Procedures. Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training and feedback on performance to department management.&nbsp; Oversees the daily office workflow, develops and recommends enhancements to process and procedures.&nbsp; </p><p>Work closely with management to review performance and quality standards on an ongoing basis. As well as motivational programs needed to achieve regulatory standards.</p><p>Acts as a back-up to the Supervisor leading meetings and handling escalations as required.</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>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree<h4>Experience</h4><p><br>Required:</p><p>At least 4 years of Appeals and Grievance experience and experience working with firm deadlines, able to interpret and apply regulations. </p><p>At least 1 year of leading process, program, or staff experience.</p><p>Preferred:</p><p>Experience in working with the disadvantage population, Medi-Cal, Covered California, and Cal MediConnect. One year lead experience in a health plan/healthcare.</p><h4>Skills</h4><p>Required:<br>Must have strong knowledge of CMS, DMHC, and DHCS regulations.</p><p>Must know Medical Terminology.</p><p>Must have excellent written and verbal communication skills. Possess skillset to effectively communicate with all levels including but not limited to members, peers, leaders, physicians, executives, and regulatory entities.</p><p>Strong analytical, coaching/mentoring skills, team building.</p><p>Ability to work effectively with diverse team members.</p><p>Must also have the ability to troubleshoot problem areas and recommend effective alternative solutions to handle irate members, and provide optimal customer service for internal and external customers.</p><p>Must be flexible with time and be able to work weekends.</p><p>Must be able to multitask and to streamline day to day operations, policies and procedures.</p><p>Must have advance PC skills including Word, Excel and Access.</p><p>Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>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>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Lead Customer Solution Center Appeals and Grievances

<p>Salary Range:&nbsp;&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 in five health plans, 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>Required:</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>Preferred:&nbsp; </p><p>Tableau experience.</p><h4>Skills</h4><p>Required:<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>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Customer Solution Center Compliance Audit Specialist II

<p>Salary Range:&nbsp;&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 Provider Network Account Manager III is responsible for all aspects of the L.A. Care (LAC) provider contracting and relationship management process, including drafting, reviewing, negotiating and implementing phases of contracts, and building, nurturing, and maintaining positive working relationships between LAC and its network of providers. Assigned accounts include multiple large provider organizations (i.e. Participating Physician Group (PPGs); Hospitals; Ancillaries; etc.), or individual practitioners, in a single or multiple locations. The Account Manager III is responsible for representing LAC in their partnership with contracted and non-contracted providers, at all times. The Account Manager III is responsible for maintaining an in-depth understanding of LAC governing regulations, policies and procedures, operating standards, provider contracts, and provider performance and needs. The Account Manager III leverages that information to identify, develop, and conduct relevant and tailored provider orientation sessions, makes educational visits about LAC practices, policies, and requirements, and works to resolve provider issues. The Account Manager III is responsible for monitoring and managing network adequacy by assuring appropriate access to services throughout L.A. County, and beyond as necessary, to comply with State and Federal requirements for all product lines of business (Medicaid, Medicare, and Commercial). The Account Manager III is responsible for the initial on-board training of new managed care contract provider partners, and for ensuring their provider accounts maintain appropriate trainings and credentials to care for LAC members.</p><p>Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Responsible for identifying, contacting, and actively soliciting qualified providers and/or provider organizations to participate with LAC; assuring the financial integrity of LAC is maintained through rate negotiation; and, ensuring contract requirements are adhered to, including language, terms, and reimbursement requirements. Responsible for the project management of all contract implementations and renegotiation functions, from pre-contracting to activation, according to pre-determined internal guidelines and financial standards, while ensuring a smooth transition of services for members. Responsible for drafting contract clauses/addenda, review, and negotiating new contracts/amendments and other contracting related documents based on LAC contracting guidelines, parameters, and standards, including leadership strategy discussions; implementing contracts/amendments across LAC; and providing in-service orientation meetings with providers. Responsible for monitoring managed care contracts for renewals and expirations.</p><p>Acts the liaison between Provider Network Management (PNM) and other internal Plan departments, as necessary, to resolve complex issues, and to effectively deliver accurate, timely, and appropriate information to their assigned accounts. Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues. Monitors timely receipt of contractually required reporting. Acquires and maintains a functional working knowledge of applicable systems like QNXT, Visual Cactus, and proprietary provider databases, and routinely relays information about additions, deletions, or changes to the LAC PNM and Provider Data Management (PDM) department. </p><p>Researches and resolves contractual interpretation, operational and/or payment issues; researches and resolves incoming escalated provider inquiries within specified guidelines; educates providers on new protocols, policies, and procedures. Ensures provider database and documentation is up-to-date, accurate, and complete.</p><p>Maintains a complete understanding of LACs reports and metrics to evaluate the performance of assigned providers and/or provider organizations, and use the data to develop and implement methods to improve </p><p>relationships with all providers. Responsible to assist in all corrective actions required, up to and including termination, following LAC policies and procedures, and applicable contractual and regulatory requirements.&nbsp; </p><h4>Duties Continued</h4><p>Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues.&nbsp; </p><p>Serve as a communication link between provider accounts and LAC. Complete regularly scheduled meetings (site visits, or conference calls) with all accounts. Translate information exchange, ideas, requests and other inquiries into actionable items for improved contracting/relationship management and enhanced operational service delivery.</p><p>Support all of the LAC PNM departments (Oversight and Monitoring; Engagement and Strategy; Data Management; and, Operations). Support all of the LAC PNM groups; assist in the development and distribution of provider engagement material (trainings, notices, newsletters); assist in oversight and monitoring efforts; implement LAC provider strategies; and assist in improving the quality of provider data, as needed.</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>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>Required:<br>Minimum of 4 years of experience in contracting and/or regulatory analysis in managed care or healthcare industry.</p><p>At least 4 years of healthcare experience in Managed Care; or, with a physician group, clinical-based organization, and/or in a hospital/facility setting.</p><h4>Skills</h4><p>Required:<br>Good organizational skills and demonstrate excellent attention to detail and follow up skills.</p><p>Knowledgeable financial and financial risk analysis.</p><p>Competent computer skills; MS Office skills required.</p><p>Excellent customer service skills with the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities and utilize time management skills to meet deadlines.</p><p>Must have excellent written and verbal communications skills and the ability to communicate effectively with management and non-management personnel, and LAC provider network physicians.</p><p><br>Possess a professional and mature demeanor at all times.</p><p><br>Ability to work in a fast-paced department independently and handle multiple tasks; work with interruptions and deal effectively with confidential information.</p><p>Preferred:</p><p>Knowledge of ICD-9, ICD-10, and Current Procedural Terminology (CPT) codes desired.</p><p>Proven ability to work with a diverse group of people, including physicians, support staff, coworkers and management.</p><p>Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others.</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>Required:</p><p>Travel to offsite locations for work.</p><p>Total Provider Management (TPM):&nbsp; Ensures that the LAC standard provider dataset is complete, accurate, and current. Provides network adequacy analysis and data to the Network Account Managers for the purpose of monitoring and evaluating existing contracts and the need for additional providers based on ongoing network adequacy analysis. Ensures timely submission of provider data, facilitates remediation of data errors, monitors provider data submission and data quality, and performs necessary data analysis.&nbsp; Responsible for the data management of assigned accounts from data collected prior to contracting, through activation, and the ongoing submission of provider data in accordance with regulatory requirements and LAC contractual requirements. </p><p>Required: Experience in provider data regulatory reporting and provider directory management.</p><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Provider Network Account Manager III

<p>Salary Range:&nbsp;&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 Product Solutions Manager II is responsible for working within the Product Strategy, Sales and Marketing (PSSM) service area to identify and implement projects, programs and initiatives that support achievement of product and enterprise goals. The position works with management, business owners and other key stakeholders to develop and manage the product go to market planning, prioritization, timelines, metrics/scorecards, budgets, Return of Investment (ROI) analysis, and working agreements for product initiatives.&nbsp; </p><h4>Duties</h4><p>Develops, designs, and implements of cyclical product life, cycle activities and specific strategic initiatives in support of optimizing the member experience while managing the ongoing evolution and strategic direction of the product line.</p><p>Support efforts to identify product management best practices. Identify impacted parties, business partners, and resources required. Develops and designs processes and product requirements that support business needs. Designs methods for integrating function and processes including applicable dependencies inclusive of enterprise initiatives.</p><p>Conducts analysis for roadmap creation, scope and execution for cross-functional execution of initiatives.&nbsp; Recognizes opportunities for product enhancements in a matrix environment and collaborative, cross functional execution.</p><p>Orchestrates, plans and executes end to end cycle strategy, development and implementation efforts for the product line.</p><p>Identifies potential risks, project charge, and scope. Recommends in design of appropriate mitigation and contingency plans. Supports in&nbsp; identifying best practices to drive product integrity, service excellence, and efficiency.&nbsp;</p><p>Provides product support to internal and external stakeholders for annual product launch. Including, sales, marketing, growth and retention efforts, delegated vendors and front line teams including assistance with benefit trainings, explanation of benefit design, member materials development and distribution, sales and marketing collateral, talking points and&nbsp; program education, configuration and benefit display requirements. Develops training materials and conduct annual and ongoing product training as required.</p><p>Manages daily processes related to the end-to-end development and fulfillment of required annual materials&nbsp; for welcome and sales kits. Oversees process and timelines from model document population, regulatory approval, design/layout, translation, and print &amp; fulfillment. Responsible for review and accuracy of approved benefits on published materials.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Public Administration or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Administration or Related Field<h4>Experience</h4><p><br><strong>Required:</strong><br>Minimum of 5 years of relevant experience in product management.</p><h4>Skills</h4><p>Required:<br>Requires deep knowledge of product development life cycle (PDLC) discipline.</p><p>Must be familiar with regulatory guidelines governing product lines; leads regulatory filing process for new/custom product initiatives.</p><p>Able to use advanced features of MS Office including Excel, PowerPoint, Word, MS Project, Visio.</p><p>Excellent written and verbal communication and presentation skills.</p><p>Ability to serve as member on cross-functional implementation or project teams.</p><p>Ability to interpret data sets and forecast future revenue streams.</p><p>Excellent interpersonal, motivational, and communication skills; with success in leading cross functional collaborative projects.</p><p>Ability to collect, analyze and recommend solutions using data and experience driven decisions.</p><p>Working knowledge of the company’s healthcare products, functions and regulatory guidelines.</p><p>Working knowledge of policy and regulatory efforts.</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>Department Specifics:</p><p>Product, Strategy, Sales &amp; Marketing: (PSSM):&nbsp;</p><p>Required:&nbsp;</p><p>Experience working in Commercial and Group Product Health Plans. Knowledge of foundational business levers impacting product performance.&nbsp;</p><p>Preferred:&nbsp;<br>Knowledge of healthcare product types inclusive of managed care and insurance products.</p><p>Additional duties include:<br>Drives Intra-team development efforts for framework and delivery model ensuring alignment with Intra-team strategic goals and objectives set forward by CPO and Exec Owner. Supports and/or drive efforts for strategic planning on product agnostic initiatives as well as strategic partnerships inclusive of entry onto the Covered CA market.</p><p>Medicare:<br>Required<br>Medicare Advantage, with experience serving duals population. Direct experience in Medicare and Duals program administration including stars, quality, financial performance review, operational functions (claims, enrollment, readiness).</p><p>Preferred:<br>Direct experience with duals population and requirement.</p><p>Medi-Cal:<br>Required:<br>Experience serving Medi-Cal population.&nbsp;</p><p>Preferred:<br>Understanding of Medi-Cal managed care model, eligibility requirements, benefits, enrollment processes, and regulatory requirements governing Medi-Cal managed care plans.&nbsp; Understanding of managed care principles and operations.</p><p>Medi-Cal Plan Partners:<br>Required:<br>Experience serving Medi-Cal population.&nbsp; Skilled in building relationships with external partners. Service oriented. Skilled in resolving conflict.</p><p>Preferred:<br>Understanding of Medi-Cal managed care model, eligibility requirements, benefits, enrollment processes, and regulatory requirements governing Medi-Cal managed care plans.&nbsp; Understanding of managed care principles and operations.</p><p>Commercial Group:<br>Required:<br>Experience working in Commercial and Group Product Health Plans.</p><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Medi-Cal Product Solutions Manager II

<p>Salary Range:&nbsp;&nbsp;$91,536.00&nbsp;(Min.) -&nbsp;$121,286.00&nbsp;(Mid.) -&nbsp;$151,034.00&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 ETL Data Integration Developer II is responsible for assisting in the design, development, and maintenance of ETL (Extract, Transform, Load) processes and data integration solutions using Informatica PowerCenter/IICS (Informatica Intelligent Cloud Services)/IDMC(Intelligent Data Management Cloud).&nbsp; This position involves working closely with senior developers, technical analysts, and business stakeholders to ensure that the data accurately and efficiently moved and transformed to meet business requirements.</p><h4>Duties</h4><p>Works in integrating data from various source systems into the data warehouse by developing and maintaining workflows, mappings, and sessions using Informatica PowerCenter/IICS (Informatica Intelligent Cloud Services)/IDMC(Intelligent Data Management Cloud)&nbsp; under the guidance of senior ETL Developers/Lead. </p><p>Participates in unit testing and documenting the test results of the codes written at until level. </p><p>Maintains documentation of ETL processes, data flows, and mappings. </p><p>Provides support for ETL processes in production environments. </p><p>Assists in resolving production issues and performing root cause analysis. </p><h4>Perform other duties as assigned.</h4><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Computer Science or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Computer Science or Related Field<h4>Experience</h4><p>Required:</p><p>4 years of experience in ETL development using Informatica PowerCenter/IICS (Informatica Intelligent Cloud Services)/IDMC(Intelligent Data Management Cloud) </p><p>2 years of experience in Developing and maintaining workflows, mappings, and sessions. </p><p>2 years of experience in writing SQL queries. </p><p>1 year of experience with JIRA tool</p><h4>Skills</h4><p>Required:</p><p>Basic knowledge of Informatica Power center/IICS (Informatica Intelligent Cloud Services)/IDMC (Intelligent Data Management Cloud).</p><p>Understanding of ETL (Extract, Transform, Load) concepts and methodologies.</p><p>Familiarity with SQL (Structured Query Language) and relational databases.</p><p>Basic understanding of data integration and data quality principles.</p><p>Strong analytical and problem-solving skills.</p><p>Good communication and interpersonal skills.</p><p>Ability to work collaboratively in a team environment.</p><p>Detail-oriented with a focus on quality and accuracy.</p><p>Healthcare domain.</p><p>Preferred:</p><p>Knowledge of AGILE development model.</p><p>Knowledge of cloud based data integration platforms such as AWS, Snowflake.</p><p>Knowledge of Data Warehouse and Data Modeling Concepts.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

ETL Data Integration Developer II

<p>Salary Range:&nbsp;&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 Provider Network Account Manager II is responsible for all aspects of the L.A. Care (LAC) provider contracting and relationship management process, including drafting, reviewing, negotiating and implementing phases of contracts, and building, nurturing, and maintaining positive working relationships between LAC and its network of providers. Assigned accounts include large provider organizations (i.e. PPGs; Hospitals; Ancillaries; etc.), or individual practitioners, in a single or multiple locations. The Account Manager II is responsible for representing LAC in their partnership with contracted and non-contracted providers, at all times. The Account Manager II is responsible for maintaining an understanding of LAC governing regulations, policies and procedures, operating standards, provider contracts, and provider performance and needs. The Account Manager II leverages that information to identify, develop, and conduct relevant and tailored provider orientation sessions, make educational visits about LAC practices, policies, and requirements, and work to resolve provider issues. The Account Manager II is responsible for monitoring and managing network adequacy by assuring appropriate access to services throughout L.A. County, and beyond as necessary, to comply with State and Federal requirements for all product lines of business (Medicaid, Medicare, and Commercial). The Account Manager II is responsible for the initial on-board training of new managed care contract provider partners, and for ensuring their provider accounts maintain appropriate trainings and credentials to care for LAC members.</p><h4>Duties</h4><p>Responsible for identifying, and contacting, providers and/or provider organizations that are interested in participating with LAC; assuring the financial integrity of LAC is maintained through rate negotiation; and, ensuring contract requirements are adhered to, including language, terms, and reimbursement requirements. Responsible for the project management of all contract implementations and renegotiation functions, from pre-contracting to activation, according to pre-determined internal guidelines and financial standards, while ensuring a smooth transition of services for members. Draft contract clauses/addenda, review, and negotiate new contracts/amendments and other contracting related documents based on LAC contracting guidelines, parameters, and standards, including leadership strategy discussions; implement contracts/amendments across LAC; and provide in-service orientation meetings with providers. Responsible for monitoring managed care contracts for renewals and expirations.</p><p>Act as the liaison between PNM and other internal Plan departments, as necessary, to resolve complex issues, and to effectively deliver accurate, timely, and appropriate information to their assigned accounts. Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues. Monitor timely receipt of contractually-required reporting. Acquire and maintain a functional working knowledge of applicable systems like QNXT, Visual Cactus, and proprietary provider databases, and routinely relay information about additions, deletions, or changes to the LAC Provider Network Management (PNM) Provider Data Management department.</p><p>Research and resolve contractual interpretation, operational and/or payment issues; Research and resolve incoming escalated provider inquiries within specified guidelines; Educate providers on new protocols, policies, and procedures. Ensure provider database and documentation is up-to-date, accurate, and complete.</p><p>Maintain an understanding of LACs reports and metrics to evaluate the performance of assigned providers and/or provider organizations, and use the data to develop and implement methods to improve relationship with all providers. Responsible to assist in all corrective actions required, up to and including termination, following LAC policies and procedures, and applicable contractual and regulatory requirements.&nbsp;</p><p>Serve as a communication link between provider accounts and LAC. Complete regularly scheduled meetings (site visits, or conference calls) with all accounts. Translate information exchange, ideas, requests and other inquiries into actionable items for improved contracting/relationship management and enhanced operational service delivery.</p><p>Supporting all of the LAC PNM departments (Oversight and Monitoring; Engagement and Strategy; Data Management; and, Operations).&nbsp; Assist in the development and distribution of provider engagement material (trainings, notices, newsletters); assist in oversight and monitoring efforts; implement LAC provider strategies; and assist in improving the quality of provider data.</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>Master's Degree<h4>Experience</h4><p>Required:</p><p>At least 3 years of experience in contracting and/or regulatory analysis in managed care or healthcare industry.</p><p>At least 3 years of healthcare experience in Managed Care; or, with a physician group, clinical-based organization, and/or in a hospital/facility setting.</p><h4>Skills</h4><p>Required:</p><p>Good organizational skills and demonstrate excellent attention to detail and follow up skills.</p><p>Knowledgeable financial and financial risk analysis.</p><p>Competent computer skills; MS Office skills required.</p><p>Excellent customer service skills with the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities and utilize time management skills to meet deadlines.</p><p>Must have excellent written and verbal communications skills and the ability to communicate effectively with management and non-management personnel, and LAC provider network physicians. </p><p>Possess a professional and mature demeanor at all times.</p><p>Ability to work in a fast-paced department independently and handle multiple tasks; work with interruptions and deal effectively with confidential information.</p><p>Proven ability to work with a diverse group of people, including physicians, support staff, coworkers and management.</p><p>Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others.</p><p>Preferred:<br>Knowledge of ICD-9, ICD-10, and CPT codes desired.</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>Required:</p><p>Travel to offsite locations for work.</p><p>TPI:&nbsp; Ensures that the LAC standard provider dataset is complete, accurate, and current. Provides network adequacy analysis and data to the Network Account Managers for the purpose of monitoring and evaluating existing contracts and the need for additional providers based on ongoing network adequacy analysis. Ensures timely submission of provider data, facilitates remediation of data errors, monitors provider data submission and data quality, and performs necessary data analysis. Responsible for the data management of assigned accounts from data collected prior to contracting, through activation, and the ongoing submission of provider data in accordance with regulatory requirements and LAC contractual requirements. </p><p>Required: Experience in provider data regulatory reporting and provider directory management.</p><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Provider Network Account Manager II

<p>Salary Range:&nbsp;&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 Regulatory Operations Project Manager II manages a portfolio of complex regulatory change management and compliance projects.&nbsp; This position will develop and manage project plans, schedule, resources, and project artifacts.&nbsp; This position will identify and monitor risks, assumptions, issues, and dependencies.&nbsp; The Project Manager will provide timely status reports and proactively escalates issues for resolution; drives continued progress for project success; develops strategies for achieving compliance with state and federal regulatory, contractual and accreditation requirements; and realigns activities to account for unforeseen challenges.&nbsp; </p><p>The Regulatory Operations Project Manager II will serve as a resource to lead stakeholders to successfully complete project deliverables on time, within scope, and on budget across multiple diverse, large-scale projects simultaneously and provide guidance to ensure understanding of requirements, assignments, priorities, and deadlines.&nbsp; </p><p>The Regulatory Operations Project Manager II closely collaborates with business owners, vendors, regulatory body representatives, and other organizational staff to understand the business needs for each project and make decisions based on what is best to ensure compliance. </p><p>A key function of this position is to serve as the lead for the development and implementation of Compliance initiates to comply with regulatory requirements. This position will oversee all aspects of the project, including quality control, risk management, and stakeholder engagement.</p><h4>Duties</h4><p>Plan, schedule, manage and track progress, including how the budget is used.&nbsp; Monitors and reports on budget status.&nbsp;&nbsp; Lead stakeholders to successfully complete project deliverables on time, within scope, and on budget across multiple diverse, large-scale projects simultaneously.</p><p>Set and manage project goals and objectives.&nbsp; Provides guidance to ensure understanding of requirements, assignments, priorities, and deadlines&nbsp; Guide stakeholders to develop project work plans that define the project purpose, scope, key milestones and tasks necessary to guide the project’s implementation</p><p>Design, develop and build program solutions to address regulatory and operational challenges that require collaboration with multiple external stakeholder senior management leaders. Maintains accurate project and regulatory change implementation data within Compliance systems and provide timely, accurate status reports. Ensure the timely submission of the executive summaries to the Compliance Leadership Team for review and approval.</p><p>Identify barriers to projects objectives and deliverables.&nbsp; Works with key stakeholders to resolve barriers and keep project on track.&nbsp; Monitor work plan updates to capture any changes that arise throughout the project implementation phase and manage progress and performance of project portfolio to track timely project execution.&nbsp; Steer and drive project direction to address and mitigate any anticipated project delays and escalate any issues/risks</p><p>Facilitate constructive dialogue among key internal and external stakeholders to ensure problems are properly assessed, analyzed and resolved. &nbsp;Manage political situations that arise when negotiating differences. &nbsp;</p><h4>Duties Continued</h4><p>Identifies and proactively escalates risks and issues for resolution.&nbsp; Ensure team members have the resources needed to meet their objectives.</p><p>Provide regular progress reports to senior management on all activities.</p><p>Oversee multiple complex projects to achieve compliance with regulatory requirements and continuous alignment with the organization’s strategic plans and objectives. Formulate and recommend solutions to address moderately complex operational and regulatory challenges in assigned projects.&nbsp; </p><p>Initiate and cultivate new relationships with external safety net stakeholders in order to build strong external partner support to facilitate completion of strategic and operational initiatives.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p>Required:</p><p>At least 4 years of experience in Program/Project Management in a managed care setting or Top 10 management consulting role in Healthcare industry.</p><p>Experience facilitating complex decision making among multiple executive stakeholders with different interests and priorities.</p><p>Experience in managing, motivating, mentoring staff and conflict resolution. </p><p>Experience in regulatory implementation and/or change management experience for a health plan or healthcare system.</p><h4>Skills</h4><p>Required:</p><p>Ability to effectively schedule, manage resources, hold project work teams accountable, and be responsible for appropriate change management practices.</p><p>Highly developed analytical and critical thinking skills. </p><p>Excellent written and oral communication skills are essential.</p><p>Knowledgeable of business operational/functional areas, best practices, and optimal procedures.</p><p>Working knowledge of Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services(CMS) and/or National Committee for Quality Assurance (NCQA) requirements.</p><p>Excellent written and verbal communication skills.</p><p>Demonstrated success in managing medium to large scale, diverse and complex projects executing simultaneously. </p><p>Critical thinking, problem solving, planning and implementation skills. </p><p>Knowledge in health care compliance.</p><p>Ability to work well independently or leading a project team/efforts with limited supervision; strong team collaboration.</p><p>Ability to manage priorities across multiple teams/projects, platforms.</p><p>Well versed in project management processes supporting project deliverables to facilitate the creation of standard project documents and artifacts.</p><p>Strong analytical, planning, and organizational skills. Strong facilitation and mentoring skills.</p><p>Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations.</p><h4>Licenses/Certifications Required</h4>Project Management Certificate<h4>Licenses/Certifications Preferred</h4>Project Management Professional (PMP)Program Management Professional (PgMP)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Skills Continuation:</p><p>Required:</p><p>Possesses excellent time management and organizational skills.</p><p>Ability to manage priorities across multiple teams/projects possesses ability to work in a fast-paced and changing environment.&nbsp; Ability to work well independently. </p><p>Strong understanding of state and federal laws and regulations and other state programs.</p><p>Proven ability to work collaboratively with business and technology communities to accomplish expected committed project outcomes.</p><p>Proficient skill in Microsoft Office Suite.</p><p>Persuasion Skills: Ensuring organizational compliance with all state and federal regulatory, contractual and accreditation requirements reduces L.A. Care's risk to state/federal sanctions and fines. Identify, report and monitor all areas of risk/noncompliance.</p><p>Preferred:</p><p>Advanced technological skills, including, but not limited to Excel, Visio, and Project. </p><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

65 L.A. Care Health Plan Jobs