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<p>Salary Range:&nbsp;&nbsp;$55,245.00&nbsp;(Min.) -&nbsp;$69,045.00&nbsp;(Mid.) -&nbsp;$82,867.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Credentialing Specialist II is responsible for managing their workload, addressing all functions for initial and re-credentialing of Health Delivery Organizations (HDOs) and initial and re-credentialing of applicants in accordance with departmental policies and procedures, National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services(CMS), California Department of Health Care Services (DHCS) requirements. This incumbent ensures data accuracy of incoming applications and re-credentialing review forms, monitoring data into Visual Cactus. Committee preparation which includes reporting, analysis, and meeting monthly deadlines. All expiries must be maintained and current. Any providers or practitioners identified as having any expired documents must be recommended for removal from the network per policies and procedures. Provider and practitioner data must be accurate and current in our Cactus database.&nbsp; </p><h4>Duties</h4><p>Ensures all applications are complete and conducts primary source verifications, identifies potential adverse events, requesting additional supporting documentation, data entry into CACTUS, prepares files for auditors QA before presenting to Credentialing Committee for decision, generating 60 day letter, scanning into Dynafile and notification to PNO. </p><p>Conducts Quality review of profiles, contract, W9 received from delegates through the PCDW application to ensure practitioner meets all regulatory requirements before being added into the network. </p><p>Monitors expiring monthly primary source verifications, scans updates into Dynafile and updates data in CACTUS, works with Auditors when potential adverse events, and/or expiring are not renewed, to review and initiate next steps. </p><p>Educates and disseminates credentialing information &amp; regulations to delegated entities. </p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p>Required:</p><p>At least 1 year of experience in a healthcare/ managed care environment with 1 year of credentialing or in a credentialing related experience.</p><h4>Skills</h4><p><strong>Required:</strong><br>Ability to audit data and make changes as appropriate with proper documentation.</p><p>Ability to audit, retrieve files/documents from our IPA and medical groups at any given time. &nbsp;</p><p>Strong knowledge of the oversight process and ability to apply requirements as per policies and procedures and instruct delegates which includes the Adds, Change, Delete (ACD) process and primary source verifications of all required elements i.e. Board Certification, License, DEA, CHDP, M/M Sanctions. &nbsp;</p><p>Confidentiality is crucial.&nbsp;</p><p>Professional computer skills.&nbsp;</p><p>Excellent communication skills (both verbal and written), high aptitude, and a facility for working on a variety of projects which require the ability to prioritize and re-prioritize, quality assurance review of credentialing files, or have a strong ability to learn. &nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Medical Staff Coordinator (CMSC)Certified Provider Credentialing Specialist (CPCS)<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>                    Healthcare Administration, Data Entry, Medicaid, Medicare, Healthcare, Administrative                                                    </p>

L.A. Care Health Plan

Credentialing Specialist 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>The Lead Community Resource Center (CRC) is 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.&nbsp; The Lead will assist the CRC Manager with developing a successful and cohesive CRC team.</p><p>The CRCs serve anyone in the community in which they are located; and therefore, this role will additionally provide expertise on developing and monitoring effective referral processes to connect non-member cases to the appropriate external resources.&nbsp; The lead will monitor and assess the planning, development, implementation, and analysis of CRC services, programming, and vendor management.</p><p>The Lead will support manager with immediate urgent decisions for center operations as applicable if manager is not available.&nbsp; 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><h4>Duties</h4><p>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; 10%</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. 10%</p><p>Mentors and trains staff on special projects and processes that support the overall operation of the CRC to provide an excellent customer experience, represent the CRC brand, and implement innovative programs.&nbsp;&nbsp; Proactively monitors risks and provides recommendations and implements mitigation plans to keep initiatives on-track.&nbsp;&nbsp; Implements continuous process improvements to workflows, processes, and customer-centric support and member engagement are well as propose solutions for the implementation of new services. 10%</p><p>Oversees member-centric customer service to respond to a wide range of simple to complex inquiries and bridges members to appropriate resources.&nbsp; Monitors implementation of child development activities and programs to support children development while parents and guardians attend a class or service appointment at the CRC.&nbsp;&nbsp; 10%</p><p>Leads implementation of extended-hour schedule by providing operational support and demonstrated commitment to offering high quality in-person service supporting CRC staff working extended-hour schedules to support members and visitors that may need services outside of regular operating hours and days based on business needs. Escalates complex member/visitor or staffing issues to manager as appropriate. 10%</p><p>Create desk level procedures and provides extensive consultation on health care access issues and identification of resource needs based on social drivers identified through a health assessment process.&nbsp; Leads cross-functional collaboration with multiple L.A. Care health plan departments.&nbsp; Implements the coordination of member service support across L.A. Care departments to ensure accountability and promote positive health care outcomes. 10%</p><h4>Duties Continued</h4><p>Leads work plan development to define building, maintaining, and nurturing meaningful relationships with key internal and external stakeholders; and, monitors the growth of the CRC partnership brand recognition.&nbsp; 10%</p><p>Assesses partnership opportunities and identifies key community stakeholders, assesses community needs, and gathers and analyzes data to inform an integrated approach to outreach activities and targeted member engagement.&nbsp; Makes recommendations for bridging members of the community to physical and health education programs and classes that will enhance health outcomes and member experience.&nbsp;&nbsp; 5%</p><p>Provides support to the CRC management in developing strategies and tactics to implement community and provider outreach and engagement initiatives to increase member traffic at a CRC and bridge members of the community to classes and resources.&nbsp;&nbsp; Oversees the&nbsp; member engagement platforms by developing and implementing&nbsp; a strategy for CRC staff to act as a liaison to the L.A. Care departments that play a role on CRC-specific marketing, communications, and promotional initiatives to promote member and community engagement.&nbsp; 10%</p><p>Creates and leads community initiatives leveraging relationships within L.A. Care and Blue Shield Promise Health Plan and with community stakeholders to promote access to health care programs, classes, and preventative services offered at the CRC. 5%</p><p>Provides training and education to other L.A. Care departments on the necessary steps to implement relevant services and activities that will resonate with and engage members of the CRC community. 5%</p><p>Performs other duties as assigned.&nbsp; 5%</p><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 in community events and leading projects focused on health care, public health, or health education.</p><p>At least 6 months of experience leading projects and/or staff, managing relationships with multiple stakeholders and have worked as a senior CRC Specialist.</p><p>Health care product experience including one of the following health care programs: Medicaid/Medi-Cal, Covered California, or Medicare Special Needs Plan.</p><p>Experience working cross-functionally with Care Management, Social Services, Health Education, and other social service or clinical teams.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p><p>Preferred: </p><p>Experience with Salesforce Customer Relationship Management (CRM) platform.</p><h4>Skills</h4><p>Required:</p><p>Strong verbal and written communication and presentation skills</p><p>Excellent organizational skills.</p><p>Must be a detail-oriented, collaborative and enthusiastic team player. </p><p>Strong ability to garner consensus on and support for new partnerships and initiatives, particularly when projects rely on participation by multiple internal or external stakeholders. </p><p>Demonstrated ability to solve complex issues and identify creative solutions to assist members and community stakeholders.</p><p>Demonstrated ability to troubleshoot problem areas, recommend effective alternative solutions, and provide optimal customer service for internal and external customers.</p><p>Demonstrates action oriented leadership ability to take on new opportunities and rewarding challenges with a sense of urgency, high energy, and enthusiasm.</p><p>Strong ability to multi-task and meet competing deadlines while maintaining attention to detail and accuracy.</p><p>Strong ability to build effective teams with persuasive skills and ability to motivate others.</p><p>Must be able to work independently or as part of a diverse team while being business-minded as well as empathetic towards members.</p><p>Ability to take initiative and act on anticipated business needs without prompting from management.</p><p>Exceptional customer service skills.</p><p>Strong ability to adapt quickly to a fast-changing environment.</p><p>Advanced proficiency in MS Office including Outlook, Word, Excel, and PowerPoint.</p><p>Strong interpersonal skills and ability to read non-verbal cues with a high level of situational adaptability.</p><p>Ability to make sound decisions with incomplete information.</p><p>Preferred:</p><p>Knowledge and understanding of the unique needs of the Medi-Cal beneficiary populations within a social service, healthcare, not-for-profit, or government setting. </p><p>Knowledge of public agencies, organizations, and other resources that support Community Resource Center visitors.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Moderate<h4>Additional Information</h4><p>Required:<br>Requires walking, standing to a significant degree, dexterity of hands and fingers to operate a variety of standard office equipment. Requires sitting most of the time, but entails bending/ lifting, pushing and/or pulling of arm or leg controls. The job may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.)</p><p>Travel to offsite locations for work</p><p>Ability to work some evenings and weekends.</p><p>Preferred:</p><p>Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese&nbsp;&nbsp; </p><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>Job Segment: </strong>                    Relationship Manager, Public Health, Medicaid, Medicare, Social Services, Customer Service, Healthcare, Service                                                    </p>

Lead Community Resource Center

<p>Salary Range:&nbsp;&nbsp;$105,267.00&nbsp;(Min.) -&nbsp;$139,478.00&nbsp;(Mid.) -&nbsp;$173,689.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Enterprise Architect Integration Engineer II is responsible for developing standards, tools and governance for capturing, storing and delivering enterprise data. This position is responsible to design and build L.A. Care's Data API work and/or SOA architecture. Working closely with the business, application and Information Technology (I.T.) infrastructure teams, the Enterprise Architect Integration Engineer II will analyze business and technical problems and develop the appropriate the framework to incorporate Master Data, event driven and batch processing entities to the Enterprise Data Management Cloud (EDMC) and/or master service bus.</p><h4>Duties</h4><p>Develop integration and architecture to meet the business needs of the company by working closely with key stakeholders and partners.</p><p>Integrate I.T. Solutions into a common framework. Enforce standards around systems technology stacks and mechanisms for governing cloud-based infrastructure.</p><p>Support in-house development teams to implement solutions. Responsible for providing technical and management guidance to all departments and works closely with development teams to ensure compliance. Supports the creation of roadmap documents, architectural documents, process documents, standards documents and governance documents. Collaborates with program-level architects across the organization on the details of the systems architecture for their particular domain.</p><p>Work closely with I.T. functional areas to identify and resolve integration and workflow considerations and issues. Responsible for assisting with the overall system design and architecture. Responsible for providing EA support to the Development department and Enterprise Architecture team. Work with other architects around business, data, systems, and security needs and how applications best participate in the overall enterprise architecture.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Computer Science or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:</p><p>At least 5 years of experience in design and implementation of data applications and integrations, using modern development tools, i.e. Java JSP applications or ORACLE/PL/SQL, or SQL Server Batch processes or similar technologies. </p><p>At least 5 years of experience designing and building solutions with SOAP, Rest API, Micro service development suites, i.e.&nbsp; Informatica IDMC/IICS, Mulesoft, or ORACLE SOA suite (ESB/BPEL/SOA/BAM).</p><p>Strong experience of managing advanced technical resources.</p><p>Demonstrated experience designing and building enterprise level canonical models.</p><p>Experience in multiple database platforms, including NoSQL, SQL Server and/or Oracle, Snowflake, Red Shift, Data Bricks, etc.</p><p>Experience working with end users to gather requirements and build technical solutions from concept to implementation.</p><p>Preferred:</p><p>Previous healthcare experience.</p><h4>Skills</h4><p>Required:</p><p>Strong understanding of process and queueing design patterns.</p><p>Strong problem-solving and analytical skills.</p><p>Excellent verbal and written communication skills with the ability to discuss and understand HealthCare business partners across all operations.&nbsp; </p><p>Must be well organized, flexible, motivated and enjoy the challenges of supporting a complex, changing environment, with attention to detail, at times under pressure, remaining flexible, proactive, resourceful and efficient. </p><p>Ability to build relationships throughout business units, our customers, and their teams to ensure that the services provided are of exceptional quality.</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><em>IT Enterprise Architecture:</em></p><p>Additional Duties and Responsibilities:</p><p>Develop Data Integration, API Integration and Application Integration architecture to meet the business needs of the company by working closely with key stakeholders and partners.</p><p>Integrate I.T. Solutions into the Enterprise Data Management Cloud framework.</p><p><em>IT Solutions Delivery:</em></p><p>Additional Duties and Responsibilities:</p><p>Develop SOA integration and Business Workflow architecture to meet the business needs of the company by working closely with key stakeholders and partners.</p><p>Integrate common SOA, BPEL, BAM, OSB, B2B, SQL, Core JAVA and Service Gateway Standards.</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                                                </p>

Enterprise Architect Integration Engineer II

<p>Salary Range:&nbsp;&nbsp;$45,760.00&nbsp;(Min.) -&nbsp;$47,823.00&nbsp;(Mid.) -&nbsp;$55,818.00&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 Claims Data Entry Clerk II is responsible for the accurate and timely data entry of claims and other documents, which includes: Keying claims for all lines of business, including complex claims. Data Entry of Claims in Core adjudication system. Checking the eligibility of members of services in order to sort claims by product. Scanning and sorting medical records. Reviewing claims for required information, returning claims to the provider when necessary. Preparing reports and ensuring that reports are accurate and generated within specified timeframes.</p><h4>Duties</h4><p>Creates and sends Rejection letters to the providers for the rejected Claims with 98.5% accuracy. Follows L.A. Care (LAC) policies and procedures. Keeps current with incoming daily receipts. Meets production standards. (50%)</p><p>Accurately sorts based on department procedures. Keeps current with incoming daily receipts. (25%)</p><p>Performs special projects and ad-hoc reporting as necessary. Projects are complete and reports are generated within the specific time frame agreed upon at the time of assignment. (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&nbsp;months&nbsp;of accurate, high-volume claims data entry or claims processing experience.</p><p>Preferred: <br>Managed care or Medi-Cal claims experience.</p><h4>Skills</h4><p><br>Proficient in Microsoft Office</p><p>Strong verbal and written communication skills</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><strong>Preferred:</strong><br>Claims Examiner Training</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>                    Data Entry, Claims, Clerical, Administrative, Insurance                                                    </p>

Claims Data Entry Clerk 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 Business Insights Data Analyst III is a key contributor responsible for supporting short and long-term operational and/or strategic business initiatives in the healthcare sector.&nbsp; This position navigates the complexities of healthcare data. This position encourages a dynamic and innovative mindset, emphasizing the importance of thinking outside the box.&nbsp; Independently navigates and analyzes data sources to derive meaningful insights. As part of the essential duties, this role involves extensive experience in data visualization, utilizing tools to translate complex datasets into visually compelling and easily understandable presentations. This position provides weaving narratives that communicate actionable insights to diverse stakeholders. </p><p>Furthermore, the Business Insights Data Analyst III collaborates in a highly matrixed environment with senior leaders, management, and line staff is essential. This position serves as a mentor to team members, leveraging analytics proficiency to drive successful outcomes. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Technical Excellence and Systematic Analysis: Completes work in a technical and systematic manner, applying standard formulas and methods prevalent in the healthcare industry.</p><p>Collects, manipulates, and analyzes data with precision, ensuring adherence to industry standards and relevance to current data trends.</p><p>Statistical Analysis and Modeling: Utilizes correlation analysis techniques to expose potential drivers in outcomes. Deploys statistical process controls to identify observations (e.g., providers, time-periods) which require additional special cause investigation. Determines and implements case-appropriate multivariate modeling techniques, such as basic regression and clustering.</p><p>Report Preparation and Visualization: Prepares detailed reports, utilizing a variety of visualizations such as graphs, charts, and dashboards effectively communicating significant results derived from data analysis. Collaborates with cross-functional teams to ensure reports align with business objectives and provide actionable insights.</p><p>Influential Communication and Project Leadership:&nbsp; Influences senior leadership, management, and line staff through compelling recommendations generated from data analysis. Drives initiatives to completion within a highly matrixed environment.</p><p>Adaptive Responsibilities: Conducts root cause analysis to identify underlying issues and drive effective solutions, leveraging data insights to address systemic problems. Adapts to evolving healthcare business and processes, demonstrating the ability to pivot and quickly learn new industry concepts and practices.</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>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Healthcare Analytics or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p>Required:<br>Minimum 4 years of collecting, manipulating, and analyzing data in business and/or healthcare</p><p>Minimum of 4 years of SQL experience, leveraging big data for complex analyses.</p><p>Extensive experience with data visualization using Tableau.</p><p>Proven experience in independently managing multiple priorities, including researching conflicting and/or inaccurate data to ensure data integrity and reliability.</p><p>Preferred<br>Experience in the healthcare industry.</p><h4>Skills</h4><p><br>Required<br>Proven hands-on experience with relational databases, including Oracle or SQL Server, and expertise in comprehensive data management and analytics platforms such as Cloudera.</p><p>Ability to articulate sophisticated analyses, trends, and strategic opportunities to clients and stakeholders through powerful data storytelling.</p><p>Strong interpersonal skills for effective engagement with management at various levels of the organization, including demonstrated ability to manage projects and initiatives.</p><p><br>Preferred<br>Strong proficiency in Python or R programming, showcasing the ability to harness advanced analytics and automation in data-driven initiatives.<br></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>

Business Insights Data Analyst III

<p>Salary Range:&nbsp;&nbsp;$105,267.00&nbsp;(Min.) -&nbsp;$139,478.00&nbsp;(Mid.) -&nbsp;$173,689.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The ETL Data Integration Developer III is responsible for the operational support of Informatica environment including but not limited to automation, job scheduling, dependencies, monitoring and maintenance of Extract, Transform, and Load&nbsp;(ETL) mappings, mapplets, and documentation. This position manages, administers and works with ETL administration in addressing systems performance including on-going optimization and tuning of Informatica environment. This position develops reliable and complex ETL processes to support new development of the Enterprise Data Warehouse, Data Marts and other Business Intelligence projects. This position also assists the Data Warehouse team in completing current Data Warehouse initiative projects. This position also performs the duties to analyze and evaluate the data source and data targets required for the ETL mapping. Design, develop and implement complex ETL processes. This position also supports and participates in source data analysis, specifically as it relates to domain definitions. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Responsible for the operational support of Informatica environment including but not limited to automation, job scheduling, dependencies, monitoring, maintenance, patches, upgrades, security, and administration. </p><p>Administers systems performance including on-going optimization and tuning of Informatica environment. </p><p>Supports and enhances existing Informatica environment and develops new, complex ETL processes to support additional design, development and deployment of the Enterprise Data Warehouse, and Data Marts.</p><p>Assists data warehouse team in completing current data warehouse initiative projects.</p><p>Analyzes and evaluates data sources.</p><p>Designs and implements complex ETL processes.</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>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Statistics or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Statistics<h4>Experience</h4><p>Required:<br>5 years of experience in Informatica ETL Developer role in Data Warehouse projects, Enterprise Data Warehouse, Online Analytical Processing (OLAP) and dimensional data modeling.</p><p>At least 3 years of proven development experience in design and development of ETL/Data Integration and Informatica Power Center Suite.</p><p>Experience with Erwin data modeling toolset.</p><p>Experience working in a PL-SQL environment.</p><p>Expert in database concepts, logical/physical design and development.</p><p>Strong experience and comprehensive proficiency with Informatica in an Oracle Data Warehouse/BI environment&nbsp;</p><p>Experience in documenting requirements and negotiating commitments&nbsp;</p><p>Strong project life cycle experience.&nbsp;</p><h4>Skills</h4><p>Required:<br>Strong database development skills including the ability to analyze, create and optimize complex SQL queries and stored procedures, working on relational databases especially Oracle &amp; MS SQL Server.</p><p>Proficient in data analysis and problem solving.</p><p>Possess excellent communication skills, both written and verbal.</p><p>Thorough knowledge of Systems Development Life Cycle (SDLC).</p><p>Must develop, foster and maintain an open, professional relationship with IT staff, management and business customers.</p><p>Excellent verbal and written communication skills.</p><p>Strong organizational and documentation skills.</p><p>Strong Understanding of DW/BI concepts.&nbsp;</p><p>Good knowledge of Software Development Lifecycle.</p><p>Understanding of development lifecycle methodology and ability to &nbsp;successfully deliver Informatica assignments.</p><p>Healthcare domain.</p><p>Proven ability to perform technology needs assessment and evaluate solution options.</p><p>The capability of performing interface analysis at the detail level.</p><p>A solid understanding of software development life cycle; and broad-based knowledge of application systems technologies.</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>

ETL Data Integration Developer III

<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>The Manager of Clinical Quality Analytics (MSA) is responsible for the operations, projects and planning of the reporting and analytics on quality programs for all of L.A. Care’s line of business (LOB) which includes Medicare Stars, Exchange Quality Rating Systems and MediCal’s Managed Care Accountability Sets, and other data-sharing and/or quality improvement programs focused on enhancing member experience and quality of life. The MCQA is responsible for analyzing, monitoring, reporting, and providing technical collaboration and data driven decision making on clinical and operational quality improvement activities related to these programs. The MCQA recommends policies, and leads process improvement efforts. </p><p>Additionally, the MCQA works with the Quality Improvement team, department leadership, and the provider network on developing plan-wide quality improvement and data strategy activities. The MCQA assists in developing a long-term plan for analytics and evaluation activities to support the quality improvement strategy and goals, including enterprise wide data and analytics solutions. The MCQA manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct and indirect staff reports.</p><h4>Duties</h4><p>Leverage data to inform targeted strategies that indicate whom to engage, with what content and through which channel and frequency: prioritize members and providers based on characteristics, such as RAF scores, open care gaps and quality improvement performance to enable a targeted and tailored outreach for members and providers through preferred channels - web, print, email, etc.</p><p>Implement a data-driven quality improvement strategy and predictive model to prioritize a set of measures that will drive higher quality ratings. &nbsp;Evaluate measures on a regular schedule to accommodate quality improvement performance changes throughout the year. These insights will enable accountable entities to make in-flight adjustments as needed, throughout the measurement year. </p><p>Establish streamlined and accurate process for quality improvement performance scorecards at the contract, provider and member level along with predictive analytics models. Work closely with QPM, HIM and other analytics teams and vendors to ensure provider web based quality tools used to monitor performance and close diagnosis and care gaps are complete, accurate, and timely and provide actionable insights at the member level. </p><p>Develop meaningful dashboards, reports, tools, and presentations to inform and influence Stars strategy and related activities.</p><p>Act as an analytics and technical subject matter expert on teams working on development and execution of Stars strategic initiatives.</p><p>Work closely with Quality Improvement team to manage and lead quality reporting and analytical strategies to enable accountable entities and stakeholders to drive quality ratings improvement for CAHPS, HOS, HEDIS, Medication Adherence and Plan Operations</p><h4>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.</h4><h4>Perform other duties as assigned.</h4><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's Degree in Business or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Public Health or Health Informatics<h4>Experience</h4><p><br>Required:</p><p>At least 6 years of experience in HEDIS, quality improvement, risk adjustment analytics, research, or related work within a healthcare context.</p><p>At least 4 years leading staff or supervisory/management experience.</p><p>Experience working with complex data sets.</p><p>Experience with developing reports in Tableau, SQL and developing datasets and data marts.&nbsp; </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>Ability to effectively collaborate and support cross functional department leadership.</p><p>Strong understanding of health care quality reporting programs, specifically Medicare Stars and HEDIS and health plan regulatory reporting requirements.</p><p>High degree of initiative and motivation.</p><p>Strong understanding of best practices in data visualization including Tableau</p><p>Strong understanding of value-based payment concepts and related engagement strategies.</p><p>Knowledge of SQL coding.</p><p>Knowledge of managed care concepts and principles and basic health plan operations.</p><p>Excellent analytical, problem solving and decision-making skills.</p><p>Ability to manage multiple tasks and projects and to delegate.</p><p>Excellent reading, oral and written communication and interpersonal skills.</p><p>Ability to work independently.</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>                    Medicare, Clinical Research, Medical Research, Public Health, Clinic, Healthcare                                                    </p>

Manager, Clinical Quality Analytics

<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>

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>

67 L.A. Care Health Plan Jobs