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<p>Salary Range:&nbsp;&nbsp;$77,265.00&nbsp;(Min.) -&nbsp;$100,445.00&nbsp;(Mid.) -&nbsp;$123,625.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Provider Network Account Manager II is responsible for all aspects of the L.A. Care (LAC) provider contracting and relationship management process, including drafting, reviewing, negotiating and implementing phases of contracts, and building, nurturing, and maintaining positive working relationships between LAC and its network of providers. Assigned accounts include large provider organizations (i.e. PPGs; Hospitals; Ancillaries; etc.), or individual practitioners, in a single or multiple locations. The Account Manager II is responsible for representing LAC in their partnership with contracted and non-contracted providers, at all times. The Account Manager II is responsible for maintaining an understanding of LAC governing regulations, policies and procedures, operating standards, provider contracts, and provider performance and needs. The Account Manager II leverages that information to identify, develop, and conduct relevant and tailored provider orientation sessions, make educational visits about LAC practices, policies, and requirements, and work to resolve provider issues. The Account Manager II is responsible for monitoring and managing network adequacy by assuring appropriate access to services throughout L.A. County, and beyond as necessary, to comply with State and Federal requirements for all product lines of business (Medicaid, Medicare, and Commercial). The Account Manager II is responsible for the initial on-board training of new managed care contract provider partners, and for ensuring their provider accounts maintain appropriate trainings and credentials to care for LAC members.</p><h4>Duties</h4><p>Responsible for identifying, and contacting, providers and/or provider organizations that are interested in participating with LAC; assuring the financial integrity of LAC is maintained through rate negotiation; and, ensuring contract requirements are adhered to, including language, terms, and reimbursement requirements. Responsible for the project management of all contract implementations and renegotiation functions, from pre-contracting to activation, according to pre-determined internal guidelines and financial standards, while ensuring a smooth transition of services for members. Draft contract clauses/addenda, review, and negotiate new contracts/amendments and other contracting related documents based on LAC contracting guidelines, parameters, and standards, including leadership strategy discussions; implement contracts/amendments across LAC; and provide in-service orientation meetings with providers. Responsible for monitoring managed care contracts for renewals and expirations.</p><p>Act as the liaison between PNM and other internal Plan departments, as necessary, to resolve complex issues, and to effectively deliver accurate, timely, and appropriate information to their assigned accounts. Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues. Monitor timely receipt of contractually-required reporting. Acquire and maintain a functional working knowledge of applicable systems like QNXT, Visual Cactus, and proprietary provider databases, and routinely relay information about additions, deletions, or changes to the LAC Provider Network Management (PNM) Provider Data Management department.</p><p>Research and resolve contractual interpretation, operational and/or payment issues; Research and resolve incoming escalated provider inquiries within specified guidelines; Educate providers on new protocols, policies, and procedures. Ensure provider database and documentation is up-to-date, accurate, and complete.</p><p>Maintain an understanding of LACs reports and metrics to evaluate the performance of assigned providers and/or provider organizations, and use the data to develop and implement methods to improve relationship with all providers. Responsible to assist in all corrective actions required, up to and including termination, following LAC policies and procedures, and applicable contractual and regulatory requirements.&nbsp;</p><p>Serve as a communication link between provider accounts and LAC. Complete regularly scheduled meetings (site visits, or conference calls) with all accounts. Translate information exchange, ideas, requests and other inquiries into actionable items for improved contracting/relationship management and enhanced operational service delivery.</p><p>Supporting all of the LAC PNM departments (Oversight and Monitoring; Engagement and Strategy; Data Management; and, Operations).&nbsp; Assist in the development and distribution of provider engagement material (trainings, notices, newsletters); assist in oversight and monitoring efforts; implement LAC provider strategies; and assist in improving the quality of provider data.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p>Required:</p><p>At least 3 years of experience in contracting and/or regulatory analysis in managed care or healthcare industry.</p><p>At least 3 years of healthcare experience in Managed Care; or, with a physician group, clinical-based organization, and/or in a hospital/facility setting.</p><h4>Skills</h4><p>Required:</p><p>Good organizational skills and demonstrate excellent attention to detail and follow up skills.</p><p>Knowledgeable financial and financial risk analysis.</p><p>Competent computer skills; MS Office skills required.</p><p>Excellent customer service skills with the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities and utilize time management skills to meet deadlines.</p><p>Must have excellent written and verbal communications skills and the ability to communicate effectively with management and non-management personnel, and LAC provider network physicians. </p><p>Possess a professional and mature demeanor at all times.</p><p>Ability to work in a fast-paced department independently and handle multiple tasks; work with interruptions and deal effectively with confidential information.</p><p>Proven ability to work with a diverse group of people, including physicians, support staff, coworkers and management.</p><p>Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others.</p><p>Preferred:<br>Knowledge of ICD-9, ICD-10, and CPT codes desired.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Required:</p><p>Travel to offsite locations for work.</p><p>TPI:&nbsp; Ensures that the LAC standard provider dataset is complete, accurate, and current. Provides network adequacy analysis and data to the Network Account Managers for the purpose of monitoring and evaluating existing contracts and the need for additional providers based on ongoing network adequacy analysis. Ensures timely submission of provider data, facilitates remediation of data errors, monitors provider data submission and data quality, and performs necessary data analysis. Responsible for the data management of assigned accounts from data collected prior to contracting, through activation, and the ongoing submission of provider data in accordance with regulatory requirements and LAC contractual requirements. </p><p>Required: Experience in provider data regulatory reporting and provider directory management.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul>

L.A. Care Health Plan

Provider Network Account Manager II

<p>Salary Range:&nbsp;&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Regulatory Operations Project Manager II manages a portfolio of complex regulatory change management and compliance projects.&nbsp; This position will develop and manage project plans, schedule, resources, and project artifacts.&nbsp; This position will identify and monitor risks, assumptions, issues, and dependencies.&nbsp; The Project Manager will provide timely status reports and proactively escalates issues for resolution; drives continued progress for project success; develops strategies for achieving compliance with state and federal regulatory, contractual and accreditation requirements; and realigns activities to account for unforeseen challenges.&nbsp; </p><p>The Regulatory Operations Project Manager II will serve as a resource to lead stakeholders to successfully complete project deliverables on time, within scope, and on budget across multiple diverse, large-scale projects simultaneously and provide guidance to ensure understanding of requirements, assignments, priorities, and deadlines.&nbsp; </p><p>The Regulatory Operations Project Manager II closely collaborates with business owners, vendors, regulatory body representatives, and other organizational staff to understand the business needs for each project and make decisions based on what is best to ensure compliance. </p><p>A key function of this position is to serve as the lead for the development and implementation of Compliance initiates to comply with regulatory requirements. This position will oversee all aspects of the project, including quality control, risk management, and stakeholder engagement.</p><h4>Duties</h4><p>Plan, schedule, manage and track progress, including how the budget is used.&nbsp; Monitors and reports on budget status.&nbsp;&nbsp; Lead stakeholders to successfully complete project deliverables on time, within scope, and on budget across multiple diverse, large-scale projects simultaneously.</p><p>Set and manage project goals and objectives.&nbsp; Provides guidance to ensure understanding of requirements, assignments, priorities, and deadlines&nbsp; Guide stakeholders to develop project work plans that define the project purpose, scope, key milestones and tasks necessary to guide the project’s implementation</p><p>Design, develop and build program solutions to address regulatory and operational challenges that require collaboration with multiple external stakeholder senior management leaders. Maintains accurate project and regulatory change implementation data within Compliance systems and provide timely, accurate status reports. Ensure the timely submission of the executive summaries to the Compliance Leadership Team for review and approval.</p><p>Identify barriers to projects objectives and deliverables.&nbsp; Works with key stakeholders to resolve barriers and keep project on track.&nbsp; Monitor work plan updates to capture any changes that arise throughout the project implementation phase and manage progress and performance of project portfolio to track timely project execution.&nbsp; Steer and drive project direction to address and mitigate any anticipated project delays and escalate any issues/risks</p><p>Facilitate constructive dialogue among key internal and external stakeholders to ensure problems are properly assessed, analyzed and resolved. &nbsp;Manage political situations that arise when negotiating differences. &nbsp;</p><h4>Duties Continued</h4><p>Identifies and proactively escalates risks and issues for resolution.&nbsp; Ensure team members have the resources needed to meet their objectives.</p><p>Provide regular progress reports to senior management on all activities.</p><p>Oversee multiple complex projects to achieve compliance with regulatory requirements and continuous alignment with the organization’s strategic plans and objectives. Formulate and recommend solutions to address moderately complex operational and regulatory challenges in assigned projects.&nbsp; </p><p>Initiate and cultivate new relationships with external safety net stakeholders in order to build strong external partner support to facilitate completion of strategic and operational initiatives.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p>Required:</p><p>At least 4 years of experience in Program/Project Management in a managed care setting or Top 10 management consulting role in Healthcare industry.</p><p>Experience facilitating complex decision making among multiple executive stakeholders with different interests and priorities.</p><p>Experience in managing, motivating, mentoring staff and conflict resolution. </p><p>Experience in regulatory implementation and/or change management experience for a health plan or healthcare system.</p><h4>Skills</h4><p>Required:</p><p>Ability to effectively schedule, manage resources, hold project work teams accountable, and be responsible for appropriate change management practices.</p><p>Highly developed analytical and critical thinking skills. </p><p>Excellent written and oral communication skills are essential.</p><p>Knowledgeable of business operational/functional areas, best practices, and optimal procedures.</p><p>Working knowledge of Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services(CMS) and/or National Committee for Quality Assurance (NCQA) requirements.</p><p>Excellent written and verbal communication skills.</p><p>Demonstrated success in managing medium to large scale, diverse and complex projects executing simultaneously. </p><p>Critical thinking, problem solving, planning and implementation skills. </p><p>Knowledge in health care compliance.</p><p>Ability to work well independently or leading a project team/efforts with limited supervision; strong team collaboration.</p><p>Ability to manage priorities across multiple teams/projects, platforms.</p><p>Well versed in project management processes supporting project deliverables to facilitate the creation of standard project documents and artifacts.</p><p>Strong analytical, planning, and organizational skills. Strong facilitation and mentoring skills.</p><p>Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations.</p><h4>Licenses/Certifications Required</h4>Project Management Certificate<h4>Licenses/Certifications Preferred</h4>Project Management Professional (PMP)Program Management Professional (PgMP)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Skills Continuation:</p><p>Required:</p><p>Possesses excellent time management and organizational skills.</p><p>Ability to manage priorities across multiple teams/projects possesses ability to work in a fast-paced and changing environment.&nbsp; Ability to work well independently. </p><p>Strong understanding of state and federal laws and regulations and other state programs.</p><p>Proven ability to work collaboratively with business and technology communities to accomplish expected committed project outcomes.</p><p>Proficient skill in Microsoft Office Suite.</p><p>Persuasion Skills: Ensuring organizational compliance with all state and federal regulatory, contractual and accreditation requirements reduces L.A. Care's risk to state/federal sanctions and fines. Identify, report and monitor all areas of risk/noncompliance.</p><p>Preferred:</p><p>Advanced technological skills, including, but not limited to Excel, Visio, and Project. </p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul>

Regulatory Operations Project Manager II

<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>Pharmacy Technician I provides support for L.A. Care Pharmacy and Formulary programs across all lines of business, support key components of the pharmacy program operations, and assists with clinical programs.</p><h4>Duties</h4><p>Review rejected claims and perform outreach for cases where action is required. (20%)</p><p>Perform clinical programs projects as assigned by Lead Technician, including Stars In. (20%)</p><p>Receive and process pharmacy-related phone calls and emails directed to Pharmacy &amp; Formulary by other departments. (15%)</p><p>Actively participates in benefit testing and other activities related to the formulary. (10%)</p><p>Participate in data analysis and is able to organize and design spreadsheets to track progress (Excel and Access). (10%)</p><p>Assist in audit deliverables. (10%)</p><p>Update necessary call logs for calls received after hours. Actively participate in rotating on-call schedule. Actively participate in weekly meetings. (5%)</p><p>Perform other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p>Required:</p><p>At least 2 years of experience as a Pharmacy Technician with at least 1 year of experience in managed care pharmacy benefit administration.</p><h4>Skills</h4><p>Required:<br>Proficiency with Microsoft Word and Excel. &nbsp;</p><p>Must be customer-service oriented and possess good telephone skills.&nbsp;</p><p>Good verbal and written communication skills.</p><p>Preferred:<br>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.</p><h4>Licenses/Certifications Required</h4>Pharmacy Technician - 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>

Pharmacy Technician I

<p>Salary Range:&nbsp;&nbsp;$47,840.00&nbsp;(Min.) -&nbsp;$57,062.00&nbsp;(Mid.) -&nbsp;$68,474.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Community Resource Center (CRC) Specialist II supports in building relationships with members of the community, L.A. Care departments, and Blue Shield of California Promise Health Plan staff (under a collaborative partnership agreement), community based agencies, government agencies, and CRC vendors and instructors. The role supports community and provider communication and engagement initiatives to increase member traffic at a CRC and provides information to members of the community to physical and health education programs, classes and resources. Acts as a key partner to support the CRC marketing and promotional initiatives to meet operational needs. Follows workflows to refer members to receive services across L.A. Care departments that support a member's health care journey to promote positive health care outcomes. Helps connect members and community participants in understanding health care access issues, identifies resource needs based on social drivers resulting from member inquiries and health assessments, and refers to the appropriate source for subject matter assistance. Provides ongoing member assistance and follow-up in select cases. Works in partnership with L.A. Care health plan departments to provide customer service, social services support, care management, health education resources, behavioral health, member engagement marketing and communication, relies on line of business product knowledge and business insight. The CRCs serve anyone in the community in which they are located; and therefore, this role will provide support on referral processes to connect non-member cases to the appropriate external resources and collaborate with key stakeholders across L.A. Care in support of positive outcomes for members.</p><p>Supports the planning and development, implementation, and analysis of CRC services, programming, and vendor management. This role may support special projects following directions and instructions from a work plan, technical procedures, and relationship management ensuring successful implementation of CRC initiatives. </p><h4>Duties</h4><p>Day-to-Day Representation: (25%)<br>Supports the coordination of member-centric customer service to respond and resolve inquiries and questions and bridges members to appropriate resources. &nbsp;Provides guidance and support to inform, guide, and educate members, community residents, and other stakeholders regarding health education programs, benefit information, resources and support available at L.A. Care and partner health plan benefits, CRC resources to meet the member/visitor needs. Collaborates with team members to create resource guides and reference materials. &nbsp;Implements the appropriate approach to identify member or visitor resource needs in complex situations and takes action to link the member/visitor to the appropriate services, programs, or resources. Actively identifies gaps in CRC services, resources, and programs, delivers recommendations for new programs and proposes solutions for the implementation of new services. &nbsp;Participates in day-to-day work operations including opening and closing of the CRC, ordering and maintaining of office supplies, and inventory. Supports CRC vendors which deliver facility maintenance. Coordinates, maintains, and schedules CRC calendar and conference rooms, including management of appointments. Prepares conference/training rooms and assists with support services, as needed. Answers incoming calls in a timely and professional manner. &nbsp;</p><p>High-Touch Customer Focus: (25%)&nbsp;<br>Performs high quality in-person service and contributes to the extended-hour schedule of the CRC to support members and visitors that may need services outside of regular operating hours and days based on business needs. Implements child development activities and programs to support children development while parents and guardians attend a class or service appointment at the CRC. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</p><p>Cross-Collaboration: (20%)<br>Supports community initiatives maintaining good 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. &nbsp;Provides information to other L.A. Care departments on services and activities that resonate with and engage members of the CRC community based on hands-on experience at the Center.</p><p>Outreach and Engagement: (15%)</p><p>Supports and nurtures relationships with key internal and external stakeholders; and, is an ambassador to promote CRC partnership brand recognition. &nbsp;Establishes relationships with key community stakeholders, informs management on community needs, and enters data to inform an integrated approach to outreach activities and targeted member engagement. &nbsp;Supports planning, development, implementation, and analysis, of member and community engagement activities to increase member traffic at the supports outreach and engagement activities to attract new L.A. Care and partner health plan members into the CRC to participate in services and programs. Provides feedback to bridge members of the community to physical and health education programs and classes which will enhance health outcomes and member experience. &nbsp;Supports communications and marketing efforts through multiple platforms to increase member traffic at assigned CRC.</p><h4>Duties Continued</h4><p>Implementing Strategic Initiatives: (15%)<br>Supports the implementation of special projects which include identifying the scope of work responsibilities, accountabilities, deliverables, key milestones, timelines, and specific tasks that &nbsp;must be completed in order to ensure project, initiatives, and events are successfully implemented within the required timeframe.<br>Supports in monitoring risks and provides recommendations for management to implement mitigation plans to keep initiatives on-track. &nbsp;Collaborates in the maintenance of consistent documentation of project deliverables, tracks and reports project status. &nbsp;&nbsp;</p><p>Performs other duties as assigned. (10%)</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:<br>At least 6 months of community work focused on health care, public health, or health education or&nbsp;</p><p>At least 6 months of operations work experience, community events, leading projects, and supporting relationships with multiple stakeholders &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;<br>Experience with data entry and reporting processes.&nbsp;</p><p>Preferred:<br>Previous experience in child development activities. &nbsp;</p><h4>Skills</h4><p>Required:<br>Ability to communicate verbally and in writing.</p><p>Organizational skills.</p><p>Detail-oriented, collaborative and enthusiastic team player.&nbsp;</p><p>Ability to assist with inquiries and identify creative solutions to assist members and community stakeholders.</p><p>Ability to troubleshoot problem areas and support effective alternative solutions and provide optimal customer service for internal and external customers.</p><p>Action oriented attitude to take on new opportunities and rewarding challenges with a sense of urgency, high energy, and enthusiasm.</p><p>Ability to multi-task and meet competing deadlines while maintaining attention to detail and accuracy.</p><p>Ability to work independently or as part of a diverse team while applying business-insight as well as empathy towards members.</p><p>Initiative to act on anticipated business needs in the operational and customer service areas.<br><br>Ability to adapt quickly to a fast-changing environment.</p><p>Knowledge of MS Office including Outlook, Word, Excel, and PowerPoint</p><p>Excellent customer service skills.</p><p>Interpersonal skills, ability to read non-verbal cues and apply situational adaptability skills.</p><p>Ability to make sound decisions with incomplete information.</p><p>Preferred:<br>Experience with the Salesforce Customer Relationship Management (CRM) platform</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.&nbsp;</p><p>Knowledge of public agencies, organizations, and other resources that support Community Resource Center visitors.</p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p>Required:&nbsp;<br>Cardiopulmonary&nbsp;resuscitation &nbsp;(CPR) and California Mandated Reporter within 90 days-of-hire</p><p>Preferred:&nbsp;<br>Management of Aggressive Behavior (MOAB), de-escalation techniques training, safe lifting practices 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>

Community Resource Center Specialist II

<p>Salary Range:&nbsp;&nbsp;$60,778.00&nbsp;(Min.) -&nbsp;$75,950.00&nbsp;(Mid.) -&nbsp;$91,166.00&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 Customer Solution Center Appeals and Grievances (A&amp;G) Specialist II &nbsp;will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. &nbsp;The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.</p><p>The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.</p><h4>Duties</h4><p>Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.</p><p>Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment.&nbsp;</p><p>Ensures integrity of A&amp;G database by thorough, timely and accurate assignment of cases. &nbsp;Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.&nbsp;</p><p>Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.</p><p>Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. &nbsp;Recommends opportunities for improvement</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree<h4>Experience</h4><p>Required:</p><p>At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.&nbsp;</p><p><br>Experience working with firm deadlines, able to interpret and apply regulations. &nbsp;</p><p>At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs. &nbsp;</p><p>Knowledge of Medical terminology and strong advocacy experience.</p><h4>Skills</h4><p>Required:<br>Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills. &nbsp;</p><p>A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.<br><br>Proficient in MS Office applications, Word, Excel and Power Point.&nbsp;</p><p>Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.&nbsp;</p><p>Preferred:<br>Proficient in MS Office applications, Access, 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>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul>

Customer Solution Center Appeals and Grievances Specialist 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 Customer Solution Center Service Representative I is responsible for a successful completion of the Member Services training program and continues to gain strong knowledge of Medi-Cal and Personal Assistance Services Council (PASC) managed care product lines.&nbsp;</p><p>The Customer Solution Center Service Representative I handles first level calls involving member eligibility verification, general program and administration questions, benefits and services, member requests for I.D. cards and Primary Care Provider (PCP) changes, and triage of calls to appropriate units or outside entities.&nbsp;</p><h4>Duties</h4><p>Answers incoming first level calls from members, potential members, providers and advocates. Handles and resolves member issues, assists members in connecting with internal units or external parties such as Plan Partners, Primary Care Physician (PCP) offices, pharmacists, etc. Provides essential information to members regarding access to care issues, coordination of care issues, benefits, Evidence of Coverage (EOC), Member Handbook, etc. Assists providers in using the Interactive Voice Response (IVR) web portal and verifying member eligibility. Documents all calls via the member data base system, QMEIS.&nbsp;<br>Ensures department compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations relating to protection of personal history information. Troubleshoots and directs calls to the appropriate departments or outside entities. (75%)</p><p>Supports robocall and ad-hoc member outreach activities as determined by business need. (15%)</p><p>Perform other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4><h4>Experience</h4><p>Required:<br>At least 6 months of customer service call center experience.&nbsp;</p><p>Data entry experience with ability to type a minimum of 40 words per minute.&nbsp;</p><p>Preferred:<br>Managed care or health plan experience.</p><h4>Skills</h4><p>Required:<br>Ability to answer a high volume of calls.</p><p>Knowledge of medical terminology.&nbsp;</p><p>Must be a strong team player, punctual, and has excellent attendance record.&nbsp;</p><p>Good understanding of service to the disadvantaged population, seniors and or people with chronic conditions or disabilities.&nbsp;</p><p>Must be a quick learner, excellent team player and customer service oriented.</p><p>Preferred:<br>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese. &nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>L.A. Care Health Plan Call Center is available 24 hours a day, 7 days a week, including holidays. Call Center work shifts are assigned based on business need and may include, but not be limited to, evenings, weekends and holidays.</p><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul>

Customer Solution Center Service Representative I

<p>Salary Range:&nbsp;&nbsp;$91,536.00&nbsp;(Min.) -&nbsp;$121,286.00&nbsp;(Mid.) -&nbsp;$151,034.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Business Intelligence Developer III position works on projects to meet business application needs. &nbsp;This position is a key contributor in creating and supporting standard and ad hoc reports to IT and Business Senior Management. This position is responsible for working with Business Analysts and key business contacts to translate functional and technical specifications into a comprehensive reporting design; Assists in requirements analysis, data analysis, data mapping, report development &amp; testing, report modifications and documentation; Determines and develops strategy and framework for consistent report standards. Under limited supervision, the individual performs research/audit and analyzes high level complex/advanced data; defines, designs and develops new/enhanced reports in support of strategic planning, portfolio and project management, resource management and development of standard processes; works closely with business clients to resolve issues and enhance systems utilizing problem solving skill; assesses and evaluates technology needs to recommend solution options; &nbsp;performs interface analysis on detail level. &nbsp;Acts as a &nbsp;Subject Matter Expert, serves as a resource and mentor for other staff.&nbsp;</p><h4>Duties</h4><p>Liaison between Information Technology ( I.T.) Business Intelligence developmental team and business clients and defining solutions. &nbsp;Work with Business Analysts and key business contacts to translate functional and technical specifications into a comprehensive reporting design.</p><p>Design of database architectures, data warehouses and data migrations. Designs, programs, tests, debugs, maintains and documents hardware/software for an advanced level of projects to meet business application needs interpreting policies, procedures and guidelines.&nbsp;</p><p>Accountable for creating business intelligence packages, and implementing user reporting solutions based upon business requirement and content knowledge. Determine development strategy and framework for consistent report development standards. Create and support standard and ad hoc reports to IT and Business Senior Management.&nbsp;</p><p>Meet with technical leaders to document and vet business requirements, identify effective reporting techniques, identify the best data sources for reach report field, identify risks and constraints, and design reporting formats. &nbsp;</p><p>Perform project management activities to drive projects to completion on schedule with junior team members and mid-Level business professionals. &nbsp;Complete projects/tasks on a timely basis, according to commitments made to stakeholders and management.</p><p>Develop, implement, and maintain ETL (extract, transform, and load) solutions to bring new data&nbsp;into the data warehouse.&nbsp;</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 &nbsp;meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Perform other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree<h4>Experience</h4><p>Required:</p><p>At least 5 years of experience in Business Intelligence and OBIEE reporting development.</p><p>At least 5 years of experience with SQL Server Integration Services (SSIS), SQL Server Reporting Services (SSRS), SQL Server Analysis Services (SSAS) and SQL Server Management Studio (SSMS).</p><p>Hands-on experience developing reports using various tools and processes.</p><h4>Skills</h4><p><br>Required:</p><p>Must have knowledge with creating Extract, Transform and Load (ETL) technology. </p><p>Ability to multitask and prioritize work.</p><p>Ability to adapt to changing tools and technologies.</p><p>Must possess communication skills to work with the project team to determine and document reporting requirements. </p><p>Advanced knowledge of applicable hardware/software configurations and programming.</p><p>Excellent verbal and written communication skills.&nbsp; </p><p>Service oriented, decisiveness, emotional intelligence, knowledge of the business, problem solving/analytical thinking, Quantitative Prioritization, Results oriented, team focus.</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>May be required to be on-call.</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>

67 L.A. Care Health Plan Jobs