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<p>Salary Range:&nbsp;&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p><br>The Manager of Medical Management is responsible for the overall day-to-day operations of the staff and activities requiring clinical licensure in the Utilization Management (UM) department. This position will work closely leaders to develop and organize the department’s work priorities and deliverables. This position will manage clinical personnel to orchestrate and oversee the completion of tasks requiring clinical determinations. This position will also be responsible for internal and external reporting, and managing the monthly data needed to ensure department metrics are met or exceeded, including but not limited to, productivity, and satisfaction of internal and external customers.</p><p>The Manager of Medical Management will also work closely with other LA Care Leaders to ensure that work is being completed accurately and timely. This position will collaborate with interfacing departments to ensure that consistent application of clinical criteria, quality of work, and productivity is maximized. This position will also lead team meetings, develop the UM clinical staff, represent the UM Clinical unit at meetings when applicable, and escalate issues as appropriate. This position manages all aspects of running an efficient&nbsp; team, including hiring, supervising, coaching, training,&nbsp; disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements. Develops and implements approved departmental policies and procedures/workflows. Implements and monitors departmental performance standards.&nbsp; Performs ongoing monitoring and evaluation of departmental operations to assure optimal efficiency and effectiveness.</p><p>Collaborates with department leadership to establish operational objectives for the business unit.</p><p>Works with members of cross-functional teams to glean and provide information pertinent to operational goals and acts as an expert resource.</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 enhancements, among others.</p><p>Ensures timely and accurate submission of reports/documents to organizational leaders and regulatory agencies.</p><p>Assures appropriate department interface with key internal and external stakeholders.</p><p>Participates in the development of and is responsible for the implementation of operational business plans and departmental objectives to support organization strategies.</p><p>Contributes to departmental statistical, quality and performance reports.</p><p>Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.</p><p>Provides input for the departmental budgets.</p><p>Leads various committees and workgroups.</p><p>Assures the maintenance of positive relationships with other departments, PPGs, other Local Initiatives and Community Based Organizations.</p><p>Implements, with approval, programs that improve the provision of services to members.</p><p>Manages content for PPG trainings/JOMS. Responsible for oversight and adequate performance of direct line of business PPG delegated activities. Work with department leadership for enhancements as necessary. Develops and sustains active communications with PPGs.</p><p>Provide administrative oversight of the L.A Care After Hours programs.</p><p>Actively participates in regulatory audits.</p><p>Performs other duties as assigned.&nbsp;&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in NursingIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><br>Required:</p><p>At least 6 years of clinical nursing experience.</p><p>At least 4 years of leading staff or supervisory/management experience.</p><p>Minimum of 3 years of relevant health plan experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Preferred:</p><p>Experience with Medi-Cal, under-served and culturally diverse populations. </p><p>Experience with state Medi-Cal regulations.</p><p>Audit/oversight experience.</p><h4>Skills</h4><p><br>Required:<br>Excellent verbal and written communication skills.</p><p>Strong problem solving, planning, and organizational skills.</p><p>Ability to maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><br><strong>Required:</strong><br>Registered Nurse (RN)</p><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><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Medical, Healthcare                                                    </p>

L.A. Care Health Plan

Manager, Medical Management

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

Supervisor, Utilization Management RN

<p>Salary Range:&nbsp;&nbsp;$206,311.00&nbsp;(Min.) -&nbsp;$278,520.00&nbsp;(Mid.) -&nbsp;$350,729.00&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 Medical Director, Community Health, acts as key medical leaders in the organization to help with the program development and oversight of Community Health.&nbsp; The Medical Director ensures that the programs align with our operational systems and tools while also performing utilization review of cases. </p><p>The Medical Director reports to the Senior Medical Director, Community Health. This position works closely with our Community Platform team as well as with the other cross-functional teams within L.A. Care (LAC). The Medical Director is responsible for supporting and ensuring that the development and implementation of Community Health protocols, policy and procedures align with regulatory and contractual requirements, internal core systems, workflows and processes. This position entails network development and relationship building with the community based organizations as well as supporting the oversight team when needed.&nbsp; The Medical Director collaborates, educates our delegated medical groups and plan partners (Anthem Blue Cross and Blue Shield/Promise), and ultimately helps to cascade the CalAIM referral process and eligibility criterial information down to our various provider networks.</p><h4>Duties</h4><p>Provide and oversee the delivery and quality assurance of prior and retrospective authorization processes for CalAIM Community Supports and related benefits, </p><p>Participate in the oversight, support and relationship management with our delegated medical groups and plan partners (Anthem Blue Cross, Care 1st and Kaiser). </p><p>Work closely with the Community Health team and the overall leadership and management accountability matrix as it relates to the program development and implementation. Share responsibility for the oversight and evaluation of the program.&nbsp; </p><p>Apply the necessary skills (clinical, operational, strategic, provider engagement) to ensure that the programs are successful for vulnerable eligible members and providers, and help ensure that the program and its participants meet the regulatory and contractual requirements as intended by CMS and California Department of Health Care Services (DHCS).&nbsp; </p><p>Perform utilization review of cases and participates in our care management programs periodically. </p><p>Provide utilization review and call coverage on scheduled weekends and holidays on a rotational basis.&nbsp;</p><p>Perform utilization reviews and determinations; and address grievance and appeals, and State Fair Hearings and periodically attend the inter-disciplinary case conferences with our Care Management teams.&nbsp;</p><p>Collaborate with hospitals, Federally Qualified Health Centers, primary care practices, and the L.A. County Departments of Health Services, Mental Health, Public Health and community-based organizations and other key partners. Conducts virtual and on-site visits with our community partners when needed. </p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Doctor of Medicine (M.D.)<h4>Education Preferred</h4><h4>Experience</h4><p>Required:<br>At least 8 years of clinical medicine experience after medical school.</p><p>Demonstrated experience working in a collaborative or matrix relationship</p><p>Experience in maintaining liaison with Federal, State, and local bodies and medical organizations.</p><p>Preferred:</p><p>Physicians with social service experience in governmental programs, social service organizations (e.g. homeless or supportive housing), justice-involved, diversion and re-entry programs and/or other non-health care related organizations. &nbsp;</p><p>Experience with working for underserved, safety net populations including those who are homeless, persons with disabilities, seniors, foster children and youths and those of various ethnic and cultural backgrounds.</p><p>Demonstrated history working with community groups and organizations.&nbsp; &nbsp;</p><p>Demonstrated experience in developing and implementing and/or evaluating programs, policies and procedures.<br></p><h4>Skills</h4><p>Required:</p><p>Demonstrated ability to provide leadership to physicians, nurses, and other health care and non-health care professionals, and an interest and involvement in the affairs of the health care and social service communities.&nbsp; </p><p>Demonstrated ability for teamwork and collaborative problem solving. </p><p>Demonstrated strong analytic ability. </p><p>Excellent written and verbal communication skills, negotiating skills, consensus building and teamwork, planning and implementation skills.</p><p>Demonstrated ability in public relations including effectiveness in working with community groups and organizations.</p><p>Understanding and knowledge of homelessness, social determinants of health, children with complex medical conditions, justice-involved populations who have significant clinical needs, and the growing age population.</p><h4>Licenses/Certifications Required</h4>Board Certified, preferably in a primary or medical specialty - 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>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>                    Public Health, Medical, Relationship Manager, Counseling, Healthcare, Customer Service                                                    </p>

Medical Director, Community Health

<p>Salary Range:&nbsp;&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&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 Director, Information Technology (I.T) Quality Assurance (Q.A) is responsible for defining and promoting a quality mindset across IT which includes responsibilities such as planning, developing, and directing quality assurance policies, programs, and initiatives. &nbsp; Evaluates and monitors tools, methodologies and automation to ensure effective testing and identification of defects. &nbsp;Directs process and product testing to ensure technical releases comply with established quality standards. &nbsp;In addition to leading the quality control and assurance functional and non-functional testers, has responsibility for the Environment Management team, Test Data Management team and Test Architects.&nbsp;</p><p>The Director of Information Technology Quality Assurance develops strategic plans for assigned areas of responsibility, &nbsp;and collaborates with senior Information technology (IT) management to ensure strategies align with IT's overall strategic goals, policies and procedures. &nbsp;In broader IT strategy development process, provides input for decisions that affect the functional area of responsibility. This position will be a change agent in our transformation to building, inspiring and guiding quality engineering teams to deliver best in class test automation frameworks. &nbsp;This position is responsible for directing all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p><br>Performs a key role within the Engineering organization as a thought leader and champion of best practices in the quality area.</p><p>Manages and promotes good working relationships across cross-functional teams. &nbsp;Collaborates with the team to ensure delivery of high quality features.</p><p>Develops, implements, enforces, and improves upon quality standards, tools, and methods to assure quality across new and existing products and services are maintained.</p><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.</p><p>Engages in the Agile Methodology ceremonies/sprints to inform appropriate data quality and testing considerations as part of acceptance criteria.</p><p>Design, roll out and drive adoption of global quality assurance and test automation practices. &nbsp;Evaluates and cross-trains on integration of technical systems and end to end data flows to ensure appropriate level of testing.</p><p>Responsible for managing the global test environments by partnering closely with DevOps/platform engineering team in integrating QA automation into the CI/CD pipelines and test automations.</p><p>Prepares briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's &nbsp;regulatory position and policy. &nbsp;Develop regulatory position and policy based on research and evidence. &nbsp;Ensures root cause analysis and feedback of findings in order to identify underlying process and reporting issues within IT quality processes and solutions. &nbsp;Based on quantitative insights developed per above, lead&nbsp;development of recommended remediation actions or initiatives to drive improvements in technology quality performance levels.</p><p>Works with cross-department leadership to delivery high quality products and services on schedule. &nbsp;</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business or Information TechnologyIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Information Technology or Related Field<h4>Experience</h4><p>Required:<br>At least 7 years of Software Quality Assurance experience in Automation Testing and Manual Testing with the demonstrated ability in the creation of quality standards, tools, and methodologies.</p><p>At least 5 years of experience managing a quality assurance team and in &nbsp;building, growing, mentoring QA associates.</p><p>Experience planning and executing end to end testing of integrated systems including validation of the integration layer.</p><p>Experience with API testing to ensure functionality, reliability, performance, and security.</p><p>Experience working with SDLC and Agile/Scrum methodologies.</p><p>Expertise in performing different types of Testing: &nbsp;Integration, Regression, Backend, System, End-to-End, User Acceptance Testing, Performance testing</p><p>Experience of DevOps in CI/CD and setting up of test environments.</p><h4>Skills</h4><p><br>Required:<br>Robust analytical skills for both existing processes and identifying areas of opportunity.</p><p>Excellent decision-making, problem-solving, team and time management skills.</p><p>Ability to effectively prioritize and execute tasks in a high-pressure environment.</p><p>Knowledge and demonstrated ability on static code analysis, identifying tech debt and catching bugs.</p><p>Ability to influence teams and team members that are not reporting to you.</p><p>Must have strong verbal and written communication and presentation skills and will include work across multiple teams.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>International Software Testing Qualifications Board (ISTQB) Certification<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><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                </p>

Director, Information Technology Quality Assurance

<p>Salary Range:&nbsp;&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&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 Director, Care Management &nbsp;will mainly be responsible for the operational component of the Care Management (CM) Department with the main goal of improving key L.A. Care members healthy and access appropriate services. The Director will also work with the CM Medical Directors and key staff in designing, enhancing and implementing programs, plan strategically and report on regulatory requirements. &nbsp;&nbsp;</p><p>One of the key initiatives is to increase our community CM presence. The Director is also responsible for providing evidence of ongoing compliance with all regulatory and accreditation requirements (i.e. health risk assessments and interdisciplinary care plan and care team programs, population health management. The Director is also responsible for outreaching and working with key stakeholders and provide subject matter expertise in support of the oversight, outreach and training of our Plan Partner Health Plans and Delegated Provider Groups.</p><p>This position will direct all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>General Essential functions:&nbsp;<br>Collaborating with the Medical Director, responsible for the operations, programming and oversight of internal L.A. Care’s Care Management Department, collaborates with internal and external delegates and any operations associated with the Care Management department. &nbsp;Functions currently include all care management programs (Complex Care Management, Care Coordination and Disease Management). &nbsp;</p><p>Ensures the CM department performs the following: &nbsp;</p><p>All contracts [(i.e. Centers for Medicare and Medicaid Service (CMS), California Department of Health Care Services (DHCS)], California Department of Managed Health Care (DMHC) regulations, applicable state and federal regulations, National Committee on Quality Assurance (NCQA) CM Certification, Management Services Agreements &amp; Other Contracts. &nbsp;</p><p>Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements. &nbsp;</p><p>Assures department meets all regulatory time frames on CM.</p><p>Develops and implements departmental policies and procedures. &nbsp;</p><p>Develops and maintains departmental statistical and performance reports. &nbsp;</p><p>Develops, implements and monitors performance standards.</p><p>Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.</p><p>Develop and maintain departmental budgets in line with organizational goals. &nbsp;Assure operational effectiveness to meet MCR targets and optimize health care resource utilization.&nbsp;</p><p>Assures appropriate staff support of Utilization Management and other relevant committees. &nbsp;</p><p>Supports the maintenance of positive relationships between L.A. Care and external groups.</p><p>Identifies and implements, with approval, programs that improve the provision of services to members. &nbsp;</p><p>Supports Clinical Assurance/Delegation Oversight in the measurement and analysis of delegated Participating Physician Group (PPG) functions.</p><h4>Duties Continued</h4><p>Internal Health Plan Operational Management:&nbsp;<br>Proactively identifies and implements operational modifications to enhance departmental performance. &nbsp;</p><p>Develops and implements operational business plans and departmental objectives to support organization strategies and tactics. &nbsp;</p><p>Interfaces with and collaborates with other service areas to assure optimal service delivery to members, compliance, and efficiency. Maintain compliance with all internal audits.</p><p>Human Resource Management:&nbsp;<br>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.</p><p>Develops and maintains a culturally sensitive work environment that promotes staff growth and education.&nbsp;</p><p><br>Completes performance appraisals in accordance with established policies and based upon achievement of the L.A. Care mission, value, objectives and management expectations.&nbsp;</p><p>Assures staff have access to appropriate training and educational opportunities.</p><p>Oversees development of staff planning, including recruitment and retention.</p><p>Data System Development and Data Analysis:<br>Directs oversight and responsible for identifying and developing business needs for complex ongoing data projects and communicating with I.T. team on business needs.&nbsp;</p><p>Assesses and revises program goals and staff training based on data analysis and review.&nbsp;</p><p>Responsible for the Policies, Procedures, Budget and Program Documentation.</p><p>Develops and regularly reviews and maintains Care Management program documents to be in compliance with all regulatory and accreditation requirements and to be in line with current program activities. Prepares briefings, reports, consultation documents and presentations that clearly articulate L.A. Care's &nbsp;regulatory position and policy. &nbsp;Develop regulatory position and policy based on research and evidence.</p><p>Vendor Management and Oversight:<br>Oversees existing contracts invoice processing, budget maintenance and compliance with contract’s scope of work.</p><p>Assesses and evaluates contract extensions and development of new vendor contract partnerships in alliance with enterprise–wide and departmental goals, objectives and members’ needs to achieve quality healthcare services and improves members’ quality of life.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Nursing<h4>Education Preferred</h4>Master's Degree in NursingIn lieu of degree, equivalent education and/or experience may be considered.<h4>Experience</h4><p>Required:</p><p>Minimum of 7 years of Care Management experience including progressively responsible leadership experience facilitating quality/process improvement, updating policies/procedures with the latest regulatory and accreditation standards.&nbsp; </p><p>At least 5 years of leading staff or supervisory/management experience</p><p>Minimum of 3 years of relevant Health Plan experience.</p><h4>Skills</h4><p><strong>Required:</strong><br>Excellent verbal, written and presentation skills.</p><p>Critical thinking skills.</p><p>Ability to efficiently and effectively assimilate information and communicate clearly and promptly to key stakeholders.</p><p>Ability to analyze and identify trends in reports to facilitate decision for enhancements to program.</p><p>Proven effective leadership skills.</p><p>Proficient with MS Office (Word, Excel, Outlook, PowerPoint, etc.)</p><p>Motivational interviewing skills.</p><p>Knowledge of compliance standards in the operational function.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Licensed Master of Social Worker (LMSW) - Active, current and unrestricted California LicenseRegistered Nurse (RN) - Active, current and unrestricted California License<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><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Social Worker, Medicaid, Medicare, Healthcare, Service                                                    </p>

Director, Care Management

<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.</p><h4>Job Summary</h4><p>The Manager of Community Programs is responsible for management and operations of programs that fall within the programs associated with the Community Health Platform Team, Housing Initiatives, Behavioral Health, Enhanced Care Management, and Social Services. This position will develop and implement operational processes to support community programs including referral management, provider training, and monitoring processes for providers such as capacity management, meeting multidisciplinary team and service requirements, and review of reporting and quality measures. </p><p>The position is responsible for prioritizing, organizing, leading, and executing program planning, program design, and project management functions necessary to achieve organizational strategic goals. Supports Director in development of programs strategy and solicits feedback from stakeholders.</p><p>This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. </p><h4>Duties</h4><p>Collaborate with internal business units to plan and integrate processes into other clinical and operational workflows, as well as Internal IT systems, Health Information Technology and Health Information Exchange.</p><p>Ensure program compliance with all regulatory requirements, including as outlined in the latest revision of Department of Health Care Services (DHCS) Policy Guides. Design, implement, and iterate operational processes for program staff and other stakeholders to ensure ongoing compliance with new regulatory guidance as well as to maintain effectiveness of the program for the changing needs of the eligible membership.</p><p>Manage staff project assignments, ensure progress is being made, deliverables/action items are on schedule and support staff with project risk mitigation by addressing any issues that may lead to delays or project non-compliance. Meet with team members on a regular basis, at least bi-weekly, to review project progress and to review project next steps. Coaches team members on project development and execution activities. Provides team members guidance on alternative methods to address challenging issues.</p><p>Identify and manage the training needs to support programmatic and operational excellence. Collaborate with L.A. Care training teams on identifying topics and developing materials for training and capacity building.</p><p>Manage quality improvement activities. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of Program. Support Director in development of program strategy and solicits feedback from stakeholders.</p><p>Manage programmatic and operational support, such as training and capacity building. Ensure execution of appropriate deliverables within agreed-upon timeframes and budget.</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 enhancements, among others.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Public Policy or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Policy or Related Field<h4>Experience</h4><p>Required:</p><p>At least 5 years of experience in health care programs related to safety net providers and low- income populations or in the publicly sponsored program space.</p><p>At least 3 years leading staff or supervisory/management experience, delegating and organizing the distribution of project and work assignments.</p><p>Experience in Medicaid, Medicare, or other government medical programs for underserved populations, including women, children, and those of diverse ethnic and cultural backgrounds.</p><p>Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Preferred:</p><p>Experience working directly with Los Angeles Safety Net providers (including physical health, behavioral health, homeless services, and/or other Community-Based Organizations).</p><h4>Skills</h4><p>Required:</p><p>Understanding of the Los Angeles County Safety Net provider community, in order to effectively drive strategic partnership and build lasting relationships. </p><p>Knowledge of healthcare delivery and finance and its impact on the Safety Net.</p><p>Excellent verbal and written communicating skills; excellent interpersonal skills.</p><p>Proficiency in MS Office applications.</p><p>Ability to solve complex problems/issues and identify creative solutions.</p><p>Ability to solve complex issues and identify creative solutions with external agencies. </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>Program Specifics:</p><p>Housing Initiatives: The Housing Initiatives team provides housing navigation and tenancy services to thousands of homeless and formerly homeless L.A. Care members using a network of contracted providers. </p><p>Responsibilities associated with the Housing Initiatives team include analysis of housing data on enrollment, payment, or claims data to identify operational problems or issues. Make recommendations to resolve problems and/or improve operations and quality of the housing program. </p><p>Community Health Platform: The Community Health Platform team supports and develops the infrastructure upon which Community Health initiatives operate. These operational and policy infrastructure includes claims processing, provider network management, community engagement, data and reporting, and compliance activities.</p><p>Enhanced Care Management (ECM): ECM is a statewide Medi-Cal benefit that provides a whole-person approach to care that address the clinical and non-clinical circumstances of high-need members through intensive interventions conducted by community-based providers. The ECM team supports and develops all of the infrastructure, policies and procedures, workflows, training, and oversight in order for the ECM program to operate effectively and meet regulatory compliance.</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>                    Public Policy, Behavioral Health, Claims, Public Health, Social Services, Government, Healthcare, Insurance, Service                                                    </p>

Manager, Community Programs

<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 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>The Supervisor, Customer Solution Center Appeals and Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals and Grievances department. This position will be accountable for leading and directing the work for the Appeals and Grievances department by monitoring the research, negotiation and resolution of all types of appeals and grievances to ensure thorough investigations are completed as outlined in the company policies and procedures. Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis. Collaborates with internal departments to ensure timely resolution. This position will be responsible for analyzing and trending for all appeals and grievances. Responsible for the development and maintenance of the appeal and grievance Policies and Procedures, workflows, Member correspondence, and training as needed, or on an annual basis. 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>Evaluate daily reports to ensure individual and team Key Performance Indicators (KPIs), SLAs, Performance Scorecards meet regulatory requirements.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances. Conduct weekly 1:1s with direct reports.</p><p>Build and maintain strong working relationships with internal departments involved in appeal and grievance resolution.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Development, maintenance and implementation of P&amp;Ps, workflow and training.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Audit preparation and providing recommendations for Corrective Action Plans from state regulatory agencies.</p><p>Supervise 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>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 in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.</p><p>At least 2 years of leading process, program, or staff or supervisory experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Preferred:</p><p>Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.</p><h4>Skills</h4><p><br><strong>Required:</strong><br>Ability to manage and organize large volumes of data.</p><p>Knowledge of regulatory and accreditation entities and their requirements.</p><p>Excellent verbal and written communication skills and interpersonal skills.</p><p>Good working knowledge of licensure and regulatory requirements, and accreditation standards.</p><p>Ability to work independently.</p><p>Ability to solve complex issues and identify creative solutions.</p><p>Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access, &nbsp;and Visio).</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned</p><p>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>                    Call Center Manager, Call Center Supervisor, Claims, Call Center, Customer Service, Insurance                                                    </p>

Supervisor, Customer Solution Center Appeals and Grievances

<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>The Information Technology Vendor Management Specialist II supports all procurement activities across the Information Technology (IT) department. Works in collaboration with various departments and vendors in creating, managing, reviewing contract items, and managing IT related contracts end-to-end through L.A. Care's contracts process, including Contract Requests, Master Agreements, Statements of Work, Requisitions, Orders, Non-disclosure Agreements, and other items as required. Assists IT Management by interacting with vendors to obtain price quotations for software license and support renewals and other items as necessary. Tracks the creation of and expenditures against IT Purchase Orders. Maintains records in L.A. Care's contract management system, which includes all vendor contract and billing related information. Supplies up to date status on contracts and invoices for status reports.</p><h4>Duties</h4><p>Participates in all aspects of IT contract development, approval, implementation and administration for L.A. Care. Coordinates, tracks, and escalates IT related contacts through the contracts process in collaboration with IT Management, business customers, vendors and legal services. Understands contract structure to identify financial terms, rates and commitments. (25%)</p><p>Works closely with Finance, vendors and L.A. Care management to ensure appropriate invoicing and payment in compliance with contract terms and rates. Tracks paid/unpaid invoices for status reporting and follow-up actions. (25%)&nbsp;&nbsp;&nbsp; </p><p>Conducts research on and analysis of various issues pertaining to Purchase Orders and Purchase Requisitions through resolution and payment processing. (25%)</p><p>Reviews and certifies price quotations, facilitates legal contract review when necessary and coordinates with vendors on the creation and use of Purchase Orders. (15%)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Performs other duties as assigned. (10%)</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>Required:</p><p>A minimum of 4 years of experience with general Information Technology functions and organization.</p><p>Preferred:&nbsp; </p><p>Experience in all aspects of contract origination, contract management, invoice verification and payment.</p><p>Ariba systems experience. </p><h4>Skills</h4><p>Required:</p><p>Careful attention to detail and accuracy for calculations and tracking of dollars, rates, contract terms, cost centers, other details of contracts, invoices, purchase orders, price quotations, orders, and other items.</p><p>Strong interpersonal skills to be able to work with a diverse group of staff and management individuals with various demands and objectives, in person, via email, chat, phone, and remotely as necessary to accomplish the objectives of the group.</p><p>Ability to organize contract work to get new contract items in place quickly. Prepare and process amendments ahead of expiration dates and other deadlines.</p><p>Ability to organize invoice processing to meet objectives for on time and early pay discount objectives.</p><p>Ability to work effectively under deadline pressure in order to move high priority contract and payment items to conclusion.</p><p>Preferred:</p><p>Proficient in a medium to advance level in Excel, including PivotTables. </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><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                </p>

Information Technology Vendor Management Specialist II

<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>

Supervisor, Appeals and Grievances Clinical Operations RN

<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 Manager, Claims directs the efforts of others in the achievement of the strategic, regulatory and operational objectives of the Health Plan. Provides direct supervision to a team of claims examiners, data entry clerks and claims assistants and continuously monitors department for compliance with regulatory requirements. Ensures all work performed within the claims department is of the highest quality and is well documented. Works with the Claims Director, Claims Managers and Supervisors to ensure the Plan’s core system produces a high level of claims auto adjudication. Develops policies and guidelines that ensure work activities are effective and well documented. Works with supervisors and department managers to develop procedural changes to improve results. Uses a variety of data analysis tools and methodologies; applies independent judgment to solve systematic problems. Recommends actions and regularly exercises discretion in regard to key business processes within the team. Develops an understanding of internal operations and how related teams interact to achieve results. Demonstrates professional courtesy and represents the company in a positive manner in all areas of internal and external communications. Responsible for appropriate record keeping, required reports, and ensuring related administrative functions are correct and maintained. The Manager must have the ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims. The Manager must demonstrate leadership and interpersonal communication skills by working collaboratively and effectively with peers, superiors and subordinates to accomplish objectives. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p><br>Provide an environment that allows staff members to flourish in their work duties. Quality levels of 99% maintained throughout the department. Continuous training of staff on all enhancements and updates to claims regulations and company policies. Develop procedure changes to improve results. Corrective action plans developed and implemented to remediate.</p><p>Maintain quality goals and production levels within the Department. Working with department supervisors, ensures that production goals associated with each work area are consistently met and that supervisors receive mentoring as appropriate to ensure department goals are met.</p><p>Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care. Claims examiners and auditors are utilizing authorized procedures that are well documented and meet the business needs of L.A. Care. All procedures meet applicable regulatory requirements.</p><p>Ability to track and trend the metrics associated with the examiner and auditor production and prepare and present written and verbal reports. Ability to research complex problem areas within the department or within the systems used by department, identify the root cause of these issues and recommend corrective actions. Continuous monitoring of work performed within the claims department. The Manager must have the ability to research problems of a complex nature and create clear and concise documentation. The Manager must work collaboratively with peers throughout the company to achieve the goals of the company. The Manager must provide mentoring to supervisors and Claims department staff ensuring that they are working effectively and meeting quality and production goals. Use data analysis and independent judgment to improve processes within the department.</p><p>Provide an environment that engages staff to fully participate in the overall functioning of the unit. The Department flourishes under the leadership of the Manager producing high quality work in a high production environment.</p><h4>Develop goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.</h4><h4>Perform other duties as assigned.</h4><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 in Business Administration<h4>Experience</h4><p>Required:</p><p>At least 5 years of Claims Management experience.</p><p>At least 3 years of supervisory/management experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p>Demonstrated depth of knowledge and experience in processing Health Plan claims of a complex nature.</p><p>Extensive experience working with COB and TPL claims in a managed care setting.</p><p>Must be highly experienced in interpreting complex contractual terms with Providers, Facilities, Plan Partners, delegated groups and related contractual scenarios.</p><p>Extensive experience in overseeing and monitoring the timeliness and accurate processing of claims.</p><h4>Skills</h4><p><br>Required:<br>Solid understanding of standard claims processing systems and claims data analysis.</p><p>Advanced working knowledge of claims coding and medical terminology.</p><p>An in-depth knowledge of claims code sets including but not limited to ICD9, ICD10, HCPCS, DRG, APC and other inpatient and outpatient coding systems.</p><p>An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.</p><p>Must have an in-depth understanding of the application of Division of Financial Responsibility (DOFR) to claims processing.</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><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Medical Coding, Data Entry, Insurance, Healthcare, Administrative                                                    </p>

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