Supervisor, Claims
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $77,265.00 (Min.) - $100,445.00 (Mid.) - $123,625.00 (Max.) 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.
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.
Job Summary
The Claims Supervisor works with the Claims Manager to oversee the daily operations of the claims department. This position is responsible for ensuring that quality levels of performance are maintained throughout the Claims Department and that all functions remain in compliance with State and Federal regulations. This position will manage new program implementations and/or system implementations. This position must maintain an up-to date knowledge of national and state-wide standards and regulations pertaining to claims processes and will ensure that production standards meet quality guidelines are met throughout the department ensuring the Plan's compliance. This position will work with department Supervisors and staff to develop procedures ensuring the achievement of goals and will continuously monitor the work performed within the Department.
The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.
Duties
Provide an environment that allows staff members to flourish in their work duties. Quality levels of 99% maintained throughout the department. Continuous training of supervisors on supervisory responsibilities as well as staff training on all enhancements and updates to claims regulations and company policies. Develop procedure changes to improve results. Corrective action plans developed and implemented to remediate any shortcomings in goal achievement.
Maintain quality goals and production levels within the Department. Ensure that Claims Department Supervisors are working effectively with their staff to ensure quality and production goals associated with each work area are consistently met by staff during their regularly scheduled work hours.
Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care.
Track and trend the metrics associated with the claims adjudication. Prepare and present written and verbal reports. Research complex problem areas within the department or within the systems used by department, and identify the root cause of these issues and recommend corrective actions.
Supervise staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
Perform other duties as assigned.
Duties Continued
Education Required
Bachelor's Degree in Business or Healthcare Related Field
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Master's Degree in Business or Healthcare Related Field
Experience
Required:
At least 3 years of experience as claims examiner working with medical facility claims and high dollar claims.
At least 2 years of leading process, program, or staff or supervisory experience.
Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
Experienced in working with Provider Dispute Resolution (PDR's).
Must have extensive experience in handling claims appeals with experience in communicating with external providers.
Skills
Required:
Sound understanding of health care code sets including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10 and revenue codes required.
Familiarity with Diagnosis Related Group (DRG) pricing.
Ability to multi-task in a high production environment.
Familiarity in working with and interpreting Provider and facility contracts and LOA's and MOU's.
Ability to draw conclusions from data analysis and to formulate corrective action plans when necessary.
Proficient in using Microsoft Word and Excel.
Must have strong coaching and mentoring skills and have the ability to build effective teams.
Must have excellent written and verbal communication skills with ability to work effectively with diverse team members.
Ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Claims, Insurance
Lead Community Resource Center
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.) 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.
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.
Job Summary
The Lead Community Resource Center (CRC) is responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. The Lead will assist the CRC Manager with developing a successful and cohesive CRC team.
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. The lead will monitor and assess the planning, development, implementation, and analysis of CRC services, programming, and vendor management.
The Lead will support manager with immediate urgent decisions for center operations as applicable if manager is not available. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff.
Duties
Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training and feedback on performance to department management. Oversees the daily office workflow, develops and recommends enhancements to process and procedures. 10%
Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. 10%
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. Proactively monitors risks and provides recommendations and implements mitigation plans to keep initiatives on-track. 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%
Oversees member-centric customer service to respond to a wide range of simple to complex inquiries and bridges members to appropriate resources. 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. 10%
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%
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. Leads cross-functional collaboration with multiple L.A. Care health plan departments. Implements the coordination of member service support across L.A. Care departments to ensure accountability and promote positive health care outcomes. 10%
Duties Continued
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. 10%
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. Makes recommendations for bridging members of the community to physical and health education programs and classes that will enhance health outcomes and member experience. 5%
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. Oversees the member engagement platforms by developing and implementing 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. 10%
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%
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%
Performs other duties as assigned. 5%
Education Required
Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Bachelor's Degree
Experience
Required:
A minimum of 4 years of experience in community events and leading projects focused on health care, public health, or health education.
At least 6 months of experience leading projects and/or staff, managing relationships with multiple stakeholders and have worked as a senior CRC Specialist.
Health care product experience including one of the following health care programs: Medicaid/Medi-Cal, Covered California, or Medicare Special Needs Plan.
Experience working cross-functionally with Care Management, Social Services, Health Education, and other social service or clinical teams.
Preferred:
Experience with Salesforce Customer Relationship Management (CRM) platform.
Skills
Required:
Strong verbal and written communication and presentation skills
Excellent organizational skills.
Must be a detail-oriented, collaborative and enthusiastic team player.
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.
Demonstrated ability to solve complex issues and identify creative solutions to assist members and community stakeholders.
Demonstrated ability to troubleshoot problem areas, recommend effective alternative solutions, and provide optimal customer service for internal and external customers.
Demonstrates action oriented leadership ability to take on new opportunities and rewarding challenges with a sense of urgency, high energy, and enthusiasm.
Strong ability to multi-task and meet competing deadlines while maintaining attention to detail and accuracy.
Strong ability to build effective teams with persuasive skills and ability to motivate others.
Must be able to work independently or as part of a diverse team while being business-minded as well as empathetic towards members.
Ability to take initiative and act on anticipated business needs without prompting from management.
Exceptional customer service skills.
Strong ability to adapt quickly to a fast-changing environment.
Advanced proficiency in MS Office including Outlook, Word, Excel, and PowerPoint.
Strong interpersonal skills and ability to read non-verbal cues with a high level of situational adaptability.
Ability to make sound decisions with incomplete information.
Preferred:
Knowledge and understanding of the unique needs of the Medi-Cal beneficiary populations within a social service, healthcare, not-for-profit, or government setting.
Knowledge of public agencies, organizations, and other resources that support Community Resource Center visitors.
Licenses/Certifications Required
Cardiopulmonary Resuscitation (CPR) Certified within 120 days of hire.
Licenses/Certifications Preferred
Required Training
Required:
Within 120 days of hire: Cardiopulmonary resuscitation (CPR) and California Mandated Reporter.
Management of Aggressive Behavior (MOAB), de-escalation techniques training, safe lifting practices training. Emergency Action Plan (EAP).
Physical Requirements
Light
Additional Information
Required:
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.)
Travel to offsite locations for work
Ability to work some evenings and weekends.
Preferred:
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
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Medicaid, Medicare, Public Health, Behavioral Health, Social Services, Healthcare, Service
Care Management Specialist II
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) 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.
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.
Job Summary
The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines.
Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases, which are those with the severest acuities or care needs and requiring the highest clinical skills and judgement. Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner.
Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team. Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member information, document contacts, and track member progress.
Duties
Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider's utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs.
Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives; reviewing member claims histories and identifies intervention opportunities through the professional standards of practice; contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits; conducting comprehensive clinical assessments as indicated; developing a member centric plan of care. Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence).
Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies.
Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions.
Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.
Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes.
Duties Continued
Meets and assesses members at L.A. Care Community Resource Centers, as needed.
Provides effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines.
Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate.
Encourages member and family empowerment through education and use of reliable resources.
Monitors and evaluates member progress: evaluates member response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assesses effectiveness of care plan's goals and interventions on a regular basis.
Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member's clinical records to promote care coordination.
Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage.
Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training.
Performs other duties as assigned.
Education Required
Associate's Degree in Nursing for Registered Nurses
Master's Degree in Social Work for Licensed Clinical Social Workers
Education Preferred
Bachelor's Degree in Nursing for Registered Nurses
Experience
Required:
Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
Experience providing care management with complex/catastrophic conditions.
Skills
Required:
Current knowledge of clinical standards of care and disease processes.
Critical thinking skill.
Excellent customer service skills.
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions.
Ability to triage immediate member health and safety risks.
Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping.
Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders.
Ability to use a personal computer, and knowledge of medical information systems.
Knowledge of and ability to comply with HIPAA compliance.
Ability to interview, assess and coordinate care. Ability to prioritize caseload.
Knowledge of community resources.
Knowledge of Medi-Cal and Medicare regulations.
Ability to work as a part of a diverse team and gain consensus and resolution of problems.
Preferred:
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.
Licenses/Certifications Required
Registered Nurse (RN);current and unrestricted California License OR Licensed Clinical Social Worker; current and unrestricted California License.
Licenses/Certifications Preferred
Certified Case Manager (CCM)
Accredited Case Manager (ACM) Certification
Case Management Nurse - Board Certified (CMGT-BC)
Required Training
Physical Requirements
Light
Additional Information
Required:
Travel to offsite locations for work.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Social Worker, Travel Nurse, Nursing, Registered Nurse, Claims, Service, Healthcare, Insurance
Vice President, Clinic Operations
El Segundo, CA job
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. The Vice President, Clinic Operations will serve as the strategic operational leader, reporting directly the regional Senior Vice President. This executive will be responsible for advancing Optum California strategy of delivering high-quality, equitable and value-based care across our regional clinics, IPA networks and affiliated clinical operations. The Vice President will work in close partnership with the regional senior medical and operational leaders to integrate clinical excellence with operational execution - ensuring care models are data-driven, patient-centered and financially sustainable.
Primary Responsibilities:
* Operational Strategy & Growth
* Execute the vision for Optum CA, aligning with enterprise-wide strategy and local market needs
* Consistently exhibit behavior and communication skills that demonstrate Optum's commitment to superior customer service, including quality, care and concern with every internal and external customer
* Complete annual budgets accurately including the development and implementation of plans to achieve budgetary goals
* Monitor resource utilization within the region and enact plans to improve efficiency and reduce expenses
* Evaluate opportunities and make recommendations for business development and expansion within the region. Work collaboratively with other departments as needed
* Quality & Performance Improvement
* Build a culture of continuous improvement using data to drive excellence.
* Monitor patient satisfaction and implements plans and programs to continually enhance services provided
* Work closely with the Regional Medical Director to enhance provider satisfaction, productivity and performance
* Ensure all operational services meet regulatory and quality standards and guidelines
* Leadership & Talent Development
* Recruit, mentor and develop clinic operations' leaders in the region
* Model a collaborative, transparent leadership style that builds trust and credibility with providers and teams
Why Join Optum CA
Optum CA is at the forefront of transforming healthcare delivery in some of the most complex and dynamic markets in the country. The Vice President role is a career-defining opportunity to:
* Lead operational strategy across one of the largest physician and IPA networks in the region
* Drive measurable improvement in quality, and equity of care delivery models
* Build the next generation of value-based care models with a mission-driven, growth-oriented team
Leadership Attributes:
* Data-driven operator: wakes up every morning focused on metrics, outliers and opportunities to drive consistency
* Change agent: proven ability to lead through transformation, aligning diverse stakeholders
* Integrator: bridges the national strategy with local execution, ensuring physicians and operators move in lockstep
* Mission-driven: committed to delivering high-quality, affordable and equitable care across diverse populations
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
* 10+ years of progressive leadership experience
* Proven track record as an operational leader in a value-based care delivery system with 6+ years of management experience in medical group operations
* Experience conducting root cause analysis and identifying optimum solutions
* Exceptional analytic orientation: uses data as the backbone for decision-making and operational improvement
* Ability to effectively direct preparation of various financial analyses and data mining activities
Preferred Qualifications:
* IPA operations management experience
* Managed care experience
* Knowledge of process improvement practices and lean methodologies
* Solid executive presence and communication skills, and successful history of building and leading high-performing teams
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $156,400 to $268,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Physical Accessibility Review Survey Reviewer II
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.) 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.
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.
Job Summary
The Physical Accessibility Review Survey (PARS) Reviewer II is responsible for the coordination, execution, and report completion of the tri-annual physical accessibility review survey assessments required by the Department of Health Care Services (DHCS) and the Centers for Medicaid and Medicare Services (CMS). The assessment is conducted at all Primary Care Physicians (PCP) and high volume specialist sites and ancillary providers that include but not limited to behavioral health providers, Community Based Adult Services agencies, skilled nursing facilities, dialysis and others. This position also verifies primary care provider's availability onsite based on L.A. Care's minimum site hours requirements which is also required by DHCS. This position is responsible for completing and uploading audit findings which are shared with other Medi-Cal health plans in Los Angeles County.
Duties
Ensure SHCS compliance by inspecting and assessing physical site/facility for potential issues concerns using the DHCS Policy Letter 12-006 Attachment C and All Plan Letter 15-023 Attachments D and E and their respective guidelines or current versions. Data entry of plan-partner audits including but not limited to: PARS assessments, FSR Survey up to 150 points, and Medical Record Review up to 30 charts. Participation in PARS collaborative with plan-partners to improve efficiency and implementation of PARS assessment through various health plans. Educate L.A. Care's FSR staff on new policies and guidelines implemented by PARS collaborative. Monitor, track and distribute PARS assessment as they are tasked in. Ensure all PARS assessments are completed timely when first assigned and PARS assessments are redone every 3 years. Work with Plan Partners to ensure data is reconciled and duplicate work is not done. (60%)
Complete audit reports accurately and timely. This includes but not limited to conducting secret shopper phone calls, completing unannounced verification site visits to, and making compliance recommendations. (15%)
Provide technical assistance and resources and conduct education to providers and their staff regarding accessibility standards and Americans with Disabilities Act (ADA) requirements. (5%)
Actively contribute to improve FSR department processes and outcomes. (5%)
Attend trainings as appropriate and as directed. (5%)
Perform other duties as assigned. (10%)
Duties Continued
Education Required
High School Diploma/or High School Equivalency Certificate
Education Preferred
Experience
Required:
Minimum of 6 months of professional work experience interacting with professional level clients.
Skills
Required:
Excellent writing and communication skills.
Proficient in using Microsoft Word, Excel and others.
Excellent organizational and time-management skills.
Excellent attention to detail.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Required:
Travel to offsite locations for work.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Data Entry, Travel Nurse, Behavioral Health, Dialysis, Medicaid, Administrative, Healthcare
Quality and Population Health Coordinator I (ALD)
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $46,800.00 (Min.) - $52,597.00 (Mid.) - $62,270.00 (Max.) 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.
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.
Job Summary
The Quality and Population Health Coordinator I (QPHC) is responsible for outreaching to members to close care gaps. The QPHC also outreaches to providers for medical record pursuit and retrieval. This position supports the L.A. Care medical groups by assisting with scheduling member appointments. While this role is a combination of remote and in office work, this role is intended to support L.A. Care medical groups by being embedded in the provider offices and providing direct outreach to L.A. Care members. The QPHC is an important member of L.A. Care's quality improvement team, helping to drive improvement in health outcomes, population health, and health equity, as well as member and provider experience.
Duties
Make outbound calls to members to assist with scheduling and coordinating services (e.g. appointments, lab tests, health screenings, other diagnostic studies, transportation, etc.). (25%)
Educate members on missing gaps in care. Encourage them to close care gaps and pursue preventative health and health promotion activities such as health fairs. (25%)
Outreach to providers to request medical reports by fax, electronic medical records, or on-site visits if needed. (15%)
Review medical records, claims, and encounter data to identify key information to help close gaps in care. (15%)
Provide support as needed for care gap closure campaigns and other quality improvement programs. (10%)
Perform other duties as assigned. (10%)
Duties Continued
Education Required
High School Diploma/or High School Equivalency Certificate
Education Preferred
Associate's Degree
Experience
Required:
At least 3 months of experience following basic workflows, procedures, and standards related to patient or provider communication and outreach.
Previous experience working in an office setting with basic office equipment such as telephones, fax machines, computers, etc.
Preferred:
Health Plan, provider practice, or health education experience.
Skills
Required:
Demonstrates deep compassion and sensitivity towards patient needs and community well-being.
Driven by strong motivation to positively impact people's lives.
Excellent verbal and written communication skills.
Excellent interpersonal skills.
Proficient with Microsoft Word, Excel, PowerPoint, and Outlook.
Skills in utilizing various online platforms and search engines to efficiently gather accurate and relevant information.
Highly organized with ability to maintain accurate notes and records.
Demonstrates high efficiency in managing tasks and consistently delivering projects to successful and reliable completion.
Ability to communicate effectively with patients and health care providers.
Preferred:
Some knowledge of HEDIS and other quality measures.
Some knowledge of quality improvement processes.
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
Licenses/Certifications Required
Active & Current Driver's License, with a clean record and Auto Insurance.
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Required:
Travel to offsite locations for work.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: EMR, Claims, Equity, Medical, Healthcare, Insurance, Finance
Care Management Community Health Worker II (12 Month Contract)
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $55,245.00 (Min.) - $69,045.00 (Mid.) - $82,867.00 (Max.) 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.
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.
Job Summary
The Care Management Community Health Worker II (CHW) is part of the care management team and is responsible for promoting members' optimal health and well-being through active engagement and helping them navigate and access health services. The CHW supports providers and the care management team through an integrated approach to care management and community outreach. Through 1:1 in-home visits as well as group education and support, the CHW helps identify members' barriers to care and their preferences, provides education and mentoring, connects them to resources, and advocates for the individual.
Duties
Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems: Educating individuals and communities about how to use health and social service systems (including understanding how systems operate). Educating systems about community perspectives and cultural norms. Building health literacy and cross-cultural communication. (10%)
Providing Culturally Appropriate Health Education and Information: Conducting health promotion and disease prevention education in a manner that matches linguistic and cultural needs of members. Providing necessary information to understand and prevent diseases and to help members manage health conditions (including chronic disease). (10%)
Care Coordination, Case Management, and System Navigation: Participating in care coordination and case management. Making referrals and providing follow-up. Coordinating transportation to services and helping address barriers to services. Documenting and tracking individual and population level data. Informing people and systems about community assets and challenges. (20%)
Providing Coaching and Social Support: Providing individual support and coaching. Motivating and encouraging people to obtain care and other services. Supporting self-management of disease prevention and management of health conditions (including chronic disease). Planning and/or leading support and health education groups. (15%)
Advocating for Individuals and Communities: Advocating for the needs and perspectives of communities. Connecting to resources and advocating for basic needs (e.g. food and housing). Conducting policy advocacy for their communities. (10%)
Building Individual and Community Capacity: Building individual capacity. Building community capacity. Training and building individual capacity with peers and among CHW groups. (5%)
Implementing Individual and Community Assessments: Participating in design, implementation, and interpretation of individual-level assessments (e.g. Health Risk Assessments, medication reviews, home environmental and safety assessment). Participating in design, implementation, and interpretation of community-level assessments (e.g. windshield survey of community assets and challenges, community asset mapping). (10%)
Duties Continued
Conducting Outreach: Case-finding/recruitment of individuals, families, and community groups to services and systems. Follow up on health and social service encounters with individuals, families, and community groups. Home visiting to provide education, assessment, and social support. Presenting at local agencies and community events. (5%)
Attending regular staff meetings, on-site monthly trainings and other meetings as requested. Managing assigned caseload. (5%)
Perform other duties as assigned. (10%)
Education Required
High School Diploma/or High School Equivalency Certificate
Education Preferred
Experience
Required:
At least 1 year of experience as a health navigator, peer support worker, outreach work, or promotora or working in a community setting and providing health education for chronic conditions, or equivalent.
Skills
Required:
Knowledge of community resources in area of residence.
Comfortable working with diverse populations.
Exceptional ability to connect and engage with people.
Ability to work in various environments including 1:1 in member's homes, clinical settings, and/ or shelters.
Excellent verbal and written communication skills.
Detail oriented, organized and possess time management skills.
Basic computer skills.
Preferred:
Motivational interviewing is desirable.
"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 ".
Licenses/Certifications Required
Licenses/Certifications Preferred
Mental Health First Aide Certification
Required Training
Preferred:
Successful completion of a Community Health Worker formal training program from a college or other education institution.
Training in health education for chronic diseases, motivational interviewing is desirable.
Physical Requirements
Light
Additional Information
Required:
Travel to offsite locations for work.
Able to work flexible job hours.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Public Health, Counseling, Medical, Healthcare
Actuarial Analyst Intern
Cypress, CA job
Internships at UnitedHealth Group. If you want an intern experience that will dramatically shape your career, consider a company that's dramatically shaping our entire health care system. UnitedHealth Group internship opportunities will provide a hands-on view of a rapidly evolving, incredibly challenging marketplace of ideas, products and services. You'll work side by side with some of the smartest people in the business on assignments that matter. So here we are. You have a lot to learn. We have a lot to do. It's the perfect storm. Join us to start Caring. Connecting. Growing together.
Actuaries are the decision-making engine for our business. That is why we support you from day one by offering guidance and assistance with exams. Our businesses serve the entire spectrum of health care participants: individual consumers and employers, commercial payers and intermediaries, physicians, hospitals, pharmaceutical and medical device manufacturers, and more, providing you with a career that is challenging, exciting, and integral in helping to write the history of healthcare.
This position will be supporting UnitedHealthcare's Employer & Individual (E&I) line of business and be located on-site in Cypress, CA with a hybrid work arrangement model of four days in office and one day remote.
Actuaries are the decision-making engine for our business. That is why we support you from day one by offering guidance and assistance with exams. Our businesses serve the entire spectrum of health care participants: individual consumers and employers, commercial payers and intermediaries, physicians, hospitals, pharmaceutical and medical device manufacturers, and more, providing you with a career that is challenging, exciting, and integral in helping to write the history of healthcare.
The Actuarial Summer Internship Program offers:
* Focused career development opportunities
* Networking with senior leadership
* Formal mentorship program
* Sponsored social and volunteer activities
* Meaningful, relevant, and current project work critical to managing our business
* Potential areas of focus may include but are not limited to:
* Healthcare Economics
* Pricing
* Reserving
* Forecasting
* Data Analytics
* Consulting
Primary Responsibilities:
* Providing moderately complex analytical support to actuaries in the development and implementation of recommendations
* Conducting and documenting moderately complex analysis and research
* Preparing, forecasting, and analyzing trends
* Initiating, compiling and preparing analytical models, tools and databases
* Assisting in developing innovative strategies, policies, and procedures
* Providing detailed summaries, reports, and recommendations to assist in managerial decision making
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualification:
* Must be actively enrolled in an accredited college/university pursuing a bachelor's or master's degree throughout the duration of the internship - internships are not intended for graduating seniors
* Pursuing a major in Actuarial Science, Mathematics, Statistics, Accounting, Finance, Economics, or another related technical field
Preferred Qualifications:
* Minimum 3.00 cumulative GPA
* 1 or more actuarial exams passed
* Demonstrated knowledge or interest in a career as an Actuary
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $27.00 to $37.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Staff Pharmacist
Gardena, CA job
**Explore opportunities with CPS,** part of the Optum family of businesses. We're dedicated to crafting and delivering innovative hospital and pharmacy solutions for better patient outcomes across the entire continuum of care. With CPS, you'll work alongside our team of more than 2,500 pharmacy professionals, technology experts, and industry leaders to drive superior financial, clinical, and operational performance for health systems nationwide. Ready to help shape the future of pharmacy and hospital solutions? Join us and discover the meaning behind **Caring. Connecting. Growing together.**
As a full-time, non-exempt **Staff Pharmacist** you'll play a vital role in delivering safe, accurate, and efficient pharmacy services. This is a hands-on opportunity to make a direct impact by ensuring the accuracy of medication orders, verifying technician-prepared products, and safeguarding controlled substances. You'll contribute to a high-performing team by mentoring new staff, maintaining seamless daily operations, and supporting the Director in optimizing pharmacy performance.
**Location:** Memorial Hospital of Gardena in Gardena, CA
**Schedule:** This full time, nonexempt position will work up to 40 hours/week in a variety of day/evening/night shifts in this 24/7 centralized pharmacy.
**Pharmacy Hours:** The centralized pharmacy is open 24/7 and supported by AllScripts and Pyxis.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
**Required Qualifications:**
+ ACPE-accredited pharmacy degree (PharmD preferred)
+ Active applicable state pharmacist license in good standing
+ 1+ years of recent acute care inpatient pharmacist experience
+ Proven skilled with pharmacy systems and Microsoft Office
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $43.22 to $77.21 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
_At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._
_UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._
_UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._
Authorization Technician II (ALD)
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.) 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.
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.
Job Summary
The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.
The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.
In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.
Duties
Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)
Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)
Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)
Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)
Perform other duties as assigned. (10%)
Duties Continued
Education Required
High School Diploma/or High School Equivalency Certificate
Education Preferred
Experience
Required:
At least 6 months of health care experience.
Experience working in a cross functional work environment.
Preferred:
Experience in Medi-Cal managed care.
1 year of experience in UM/Prior Authorization.
Skills
Required:
Demonstrated proficiency in Medical Terminology required.
Strong verbal and written office communication skills.
Proficient with Microsoft Office Suite and Adobe PDF. and
Excellent organizational, interpersonal and time management skills.
Must be detail-oriented and an enthusiastic team player.
Preferred:
Knowledge of QNXT computer systems a plus.
Knowledge of the UM patient referral process.
Knowledge of member's health plan eligibility.
Knowledge of member's benefits coverage.
Knowledge of Health Plan regulations.
Knowledge of HMO/UM functions.
Knowledge of ICD-10/CPT coding.
Proficient utilizing electronic medical records and documentation programs.
Licenses/Certifications Required
Licenses/Certifications Preferred
Medical Coding Certification
Required Training
Physical Requirements
Light
Additional Information
Required:
Weekends and holidays hours may be required, as well as OT based on a business need.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Data Entry, Claims, Medical Coding, EMR, Administrative, Insurance, Healthcare
Specialty Health Plans Auditor III Finance **$5,000 Sign On
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) 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.
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.
Job Summary
The Specialty Health Plans Auditor III, Finance, is offering a $5,000 sign-on offer. This role is responsible for all aspects of planning, execution, reporting, and corrective action plans, monitoring of financial solvency for specialty health plans and vendors. This includes medical, vision, dental, behavioral health, transportation, and telehealth services providers. These audits are intended to ensure that L.A. Care delegates comply with applicable regulatory requirements and L.A. Care contractual agreements across all lines of business.
Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.
Duties
Performs financial audits and/or financial analyses for Specialty Health Plans on the quarterly and annual basis.
Performs financial analyses for L.A. Care vendors on the quarterly and annual basis.
Provides timely and accurate deliverables to ensure financial solvency compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors.
Collaborates in the creation and implementation of standardized audit workpaper and reporting templates.
Is cross trained on financial solvency reviews for Participating Physician Group (PPGs), PPs, and capitated hospitals.
Reviews and updates annually the department's Policies and Procedures (P&Ps). Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission.
Supports the formalization of key internal processes and monitoring tools.
Accountable for the completion of requests from Legal Department, Delegation Oversight's monitoring oversight and reporting.
Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors.
Collaborates on the design, implementation, and reporting of special projects.
Collaborates on the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.
Collaborates on the assessment, communication, and implementation of regulatory requirements that may impact internal processes.
Duties Continued
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.
Performs other duties as assigned.
Education Required
Bachelor's Degree in Accounting or Related Field
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Master's Degree
Experience
Required:
At least 4 years of experience in conducting financial audits.
At least 5 years of related experience in the managed health care industry.
Skills
Required:
Excellent analytical and critical thinking skills.
Action-oriented, self-starter, and excellent motivator.
Excellent verbal and written communication skills.
Able to prioritize assignments, and able to independently with minimum supervision.
Ability to interface professionally with both internal and external customers at all levels of the organization.
Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).
Licenses/Certifications Required
And/Or any of the following Licenses/ Certifications:
Certified Public Accountant (CPA)
Certified Internal Auditor (CIA)
Certified Fraud Examiner (CFE)
Certified Management Accountant (CMA)
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Accounting, CPA, Behavioral Health, Internal Audit, Telemedicine, Finance, Healthcare
Sr. Manager, Program and Project Management
Long Beach, CA job
Your Role
The Senior Manager, Program Development and Operations, Provider Performance Enablement provides oversight and direction for the strategy, design, development, and implementation of solutions to support provider and health systems performance enablement. The Senior Manager reports to the Director, Program Development and Operations, Provider Performance Enablement. In this role, you will work with the Director and other Blue Shield of California (BSC) business leaders to identify issues and design, develop, and implement the strategy for all work within the Provider Performance teams (to improve provider performance across BSC). This role strategically sources and identifies internal and external partners to implement the goals and objectives of the Provider Performance Enablement teams. Additionally, this role interfaces across the enterprise, working with Program Managers, Senior Managers, Directors, Senior Directors and Vice President leaders across Healthcare Quality & Affordability, Information Technology, Finance, Actuary, Transformation & Operations, and Portfolio Management Office. Communicating with BSC and external vendor senior leadership, interfacing, and collaborating directly with providers, hospitals, health systems, and other stakeholders is critical.
The Senior Manager leads identification and mitigation of risks, conducts data analysis to measure program effectiveness, and prepares comprehensive reports for key stakeholders. They contribute to process optimization and the development of best practices, while also conducting implementation study to examine factors influencing the adoption and implementation of evidence-based interventions.
The Senior Manager leads the assessment of organizational readiness, provides consultation and training to enhance implementation competence, and engages with diverse stakeholders to ensure the relevance and feasibility of implementation efforts. Monitoring and evaluation, dissemination of findings, and staying informed of current literature and advancements in implementation science are also crucial aspects of this role.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Knowledge and Experience
Requires a college degree or equivalent experience
Requires at least 10 years of prior relevant experience, including 4 years of management experience
Requires healthcare operations leadership experience
Lean Sigma, Six Sigma or experience with business process management, or other quality improvement methodologies preferred
Prior healthcare project and program management experience; PMP certification with experience in Agile project delivery methodology preferred
Exceptional verbal and written communication and program/project management skills, including an ability to communicate effectively at an executive level, with a keen attention to detail
Ability to prioritize and manage work and trade-offs against critical project timelines in a fast-paced environment
Excellent influence and engagement skills in building alignment and accountability without formal ownership or authority over talent resources
Ability to build strong and sustainable trusting relationships and the capability to interact within all levels of the organization, internally and externally
Ability to work cooperatively and strategically in a team environment with all levels of professional, technical, and administrative staff and to integrate resources on a timely and organized basis
Acumen to handle complex situations and multiple responsibilities simultaneously with the urgency of immediate demands on the operations
Strategic thinker who has an eye for detail, is organized, and can manage multiple programs simultaneously
Strong communicator with PowerPoint and storyboarding skills. Ability to present information clearly and concisely to various audiences
Ability to deal with highly confidential information and act as a liaison between the business leaders and other constituencies, both internal and external
Your Work
In this role, you will:
Lead and develop the core operational model and timeline for the implementation of all work supporting the department's success metrics including monitoring and results reporting
Collaborate with stakeholders to define initiative objectives, scope, and success criteria
Define and track key performance indicators (KPIs) to measure the effectiveness and impact of initiatives
Lead the development of detailed project plans, timelines, and resource allocation strategies.
Conduct organizational assessments to identify barriers and facilitators to implementation, including organizational culture, leadership support, resources, and system-level factors
Lead the creation of successful metrics for the Provider Performance Enablement (PPE) department and teams, informed by internal SME's/stakeholders and external (providers) in the required areas of focus - quality, affordability, risk adjustment, utilization management, and operations
Design, develop and maintain all programs, resources and tools supporting the core work of the PPE department
Support the implementation, timeline, and on-going assessment/evaluation plan for the Provider Engagement Strategy
Support and lead the identification of areas for BSC organizational process change and oversee change implementation as required through feedback from SMEs/stakeholders and external providers to increase BSC organizational efficiency and provider trust
Support and lead research to identify new tools and programs to support provider enablement
Support and lead the development of business requirements to build new tools and programs in support of provider performance enablement in partnership leveraging HQA performance capabilities
Implement new tools to support performance enablement (i.e. Provider adoption)
Provide support and oversight for contracting processes and related monitoring of vendors that support provider engagement
Support and lead business case development to support new tools and programs for provider enablement including all programmatic impact and financial analysis and projections
Support the development of an enhanced provider performance reporting platform informed by internal SME's/stakeholders and external (providers). Partner with internal stakeholders to own/drive implementation of platform
Support and guide development of platform updates and enhancements post-launch to ensure platform long-term effectiveness
Monitor platform user experience and identify areas for enhancement
Provide performance insights to inform payment models, contracting and navigation of members to high-value sites of care
Build, manage, and lead a high performing team. Lead a team while fostering a healthy team culture, prioritizing equity and inclusion and providing a great place to work
Serve as a resource and mentor to other Senior Managers and Program Managers as appropriate
Auto-ApplyNetwork Administrator III
L.A. Care Health Plan job in Los Angeles, CA
Salary Range: $91,536.00 (Min.) - $121,286.00 (Mid.) - $151,034.00 (Max.) 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.
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.
Job Summary
The Network Administrator III is responsible for providing network support for the mission critical network systems for L.A. Care. This involves troubleshooting IP equipment/LAN/WAN problems, routine administration tasks, and performance tuning. This position acts as an escalation point for the junior network staffs regarding network related problems.
Performs troubleshooting of LAN/WAN equipment i.e. CISCO, etc. Conduct daily routine administration and maintenance of all network devices. Monitors network to ensure constant uptime. Supports and maintains firewall and network security policies and IDS. Implements new technologies platforms for the network environment. Must be able to troubleshoot issues quickly to resolve the problem. Participate in Disaster Recovery Exercises to demonstrate the capability of establishing network connectivity in the event of an outage. Provide support in a 7x24 operation. Prioritization, Multitasking, Training, I.T. projects, and writing SOPs. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.
Duties
Work closely with other technical teams to determine future network needs and plan for network changes.
Develop methods and tools to be used to test to implement new LAN/WAN equipment.
Configure routing protocols such as EIGRP, OSFP, and BGP.
Engage in regular network troubleshooting and resolve network connectivity issues.
Analyze the current network structure and submit comprehensive reports to manager on how to make the network more efficient.
Create projects that are designed to either add functionality required by the company or to address ongoing network failure issues.
Maintain network performance by performing network monitoring and analysis, and performance tuning, troubleshooting network problems and escalating problems to vendor or lead network administrator.
Secure network by developing network access, monitoring, control, and evaluation, maintaining documentation.
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.
Perform other duties as assigned.
Duties Continued
Education Required
Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Experience
Required:
Minimum of 5 years of experience as a network administrator.
Skills
Required:
Must have critical thinking skills and a team player.
Must have strong written and verbal communication, project management, and organization skills.
Demonstrate the ability to lead the network team on technical issues and act as a backup to the manager.
Demonstrate working knowledge of network equipment and software (Cisco Routers, Switches, firewalls, F5 Bigip, IPS/IDS, LAN/WAN).
Demonstrate working knowledge in routing protocols such as BGP, EIGRP and OSFP.
Demonstrate working knowledge in Layer 2 network switching such as VLAN, Trunking, VTP and others.
Demonstrate working knowledge in advance network troubleshooting and work with other teams or departments to resolve complex issues.
Licenses/Certifications Required
Cisco Certified Network Professional (CCNP)
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental and Vision
* Wellness Program
* Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
MSW Social Worker - Arcadia, CA
Arcadia, CA job
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Social workers are responsible for providing social work services to patients and families. They function as a member of the departmental team which includes educating the patient, family and members of the healthcare team regarding benefits, community resources, referrals for counseling and other pertinent information. Social workers are also responsible for triaging referrals and collaborating on cases with other members of the healthcare delivery team. In addition, social workers must be able to assist the patient in a sensitive and supportive manner, while acting as an advocate on behalf of the patient.
Primary Responsibilities:
* Assesses patient and family psychosocial needs and develops plan of care in concert with patient, physicians, nurses and other members of the departmental team
* Links patients/family to appropriate community resources including but not limited to, information/referral to sources of financial assistance, transportation, support groups, and other community services
* Documents patient/family status, diagnosis, treatment plan, goals, and interventions, evaluation results, observations and progress in medical record
* Serves as patient advocate and liaison with physicians, families, insurance company, community agencies and others as needed to ensure continuity of care
* Provides discharge planning based on meeting identified goals of the treatment plan anywhere
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
* Licensed Master's degree-level clinician in Psychology, Social Work, Counseling or Marriage or Family Counseling, or Licensed Ph.D., or an RN with 2 or more years experience in behavioral health
* Licenses must be active and unrestricted
* Basic Microsoft Word skills
* Driver's License and access to a reliable transportation
Preferred Qualifications:
* Case management experience
* Experience in managed care
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
Nocturnist/Hospitalist - Per Diem
Los Angeles, CA job
Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work.SM
Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.
Life Changing Work
Want to make a real difference in the lives you touch? LOOK NO FURTHER.
Optum is a physician-led, close-knit team that has been long-respected in Southern California. We are passionate about patients. We are leading the state of California toward better healthcare practices. And we are looking for amazing doctors like you.
As part of our continued growth, Optum is seeking a per diem Hospitalist to join our team in Chatsworth, CA. The Clinicians we seek are those who practice medicine with a focus on patient care, not volume. We want our Clinicians to take the time needed to truly address the patient's needs.
If you're looking to join a physician-led community that is making a difference in healthcare, Optum is the place for you.
Position Highlights:
* Hospitals: Holy Cross, Valley Presbyterian, Saint Joseph OR Northridge
* Shifts 8am - 8pm. 8pm - 8am, or Northridge 7am - 7pm
* Conduct hospital rounds on all patients referred to the service
* Provide patient care in a manner consistent with hospital medical staff by-laws and referring physician requests
* Communicates with families, referring physicians, specialists, administration and hospital departments in the care and treatment of patients referred to the service
* Work with hospitals and clinical staff, social services, utilization management and other members of the interdisciplinary teams
* Collaborates with interdisciplinary team to discuss patients progress, variances and achievement of expected outcomes and plan of care
* Assumes responsibility to ensure that all necessary documentation is accurate, complete, and timely including medical records, billing/coding and any other such documentation as requested by hospital from time to time
* Attends and completes all specific competencies and annual organizational requirements
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
* Unrestricted California State Medical License
* Current California DEA certificate
* Board Certified Internal Medicine
* 1+ years' experience preferred
* EMR proficient
* Positive attitude and strong work ethic
* Self-starter with ability to practice with a high degree of independence
* Strong verbal and written communication skills
* Managed Care and Medi-Cal experience desirable
* Full COVID-19 vaccination is an essential requirement of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
We offer competitive compensation and comprehensive benefit package including medical malpractice coverage and tail policy, generous, CME time and dollars, medical, dental and vision benefits, company paid life insurance, bonus potential.
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
About Us:
We're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. All this together is your time to do your life's best work. SM
California Residents Only: The hourly range for California residents is $129.00 to $171.00. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
2026 Winter/Spring Value-Based Platform Internship
Los Angeles, CA job
Your Role
The Value-Based Platform team oversees and executes operations and implementations for the Pay for Value program. The program is housed under Network Strategy & Provider Partnerships and involves applying value-based payment models to care delivery with the goal of lowering health care costs while improving outcomes via the use of incentives tied to performance within the model. The value-based platform intern will report to the Senior Manager on the Value-Based Platform team. In this role, they will support a variety of tasks related to operations, such as report delivery, quality assurance and payment processing.
Your Knowledge and Experience
Actively pursuing a bachelor's or master's degree in public health, business, health care or related field
Must reside in the state of California for the duration of the internship
Minimum 1 year of related professional experience, project, or coursework
Strong communication skills required, particularly writing for publication
Proactive, solution focused mindset with demonstrated creative, problem-solving skills
Knowledge of the key synergies necessary among practices, payers, community, populations, and policy leaders to better align health care transformation efforts
Passionate about changing healthcare and challenging the status quo to advance health equity
Proficient in Microsoft applications, including Outlook, Word, Excell, and SharePoint
Pay
$25.00 per hour for Undergraduate
$30.00 per hour for Graduate
About Our Internships
Our paid internship program is thoughtfully curated to provide students experience and exposure to the health professional industry. Interns will be given the opportunity to get hands-on experience with real work projects, build meaningful relationship and connections within the organization, and experience our mission and enterprise goals through our program curriculum centered on our leadership model (Personal, People, Thought, and Results Leadership). To see more about our internship program, check out this video.
Our Winter/Spring 2026 Internship is January 26th through May 15th, 2026.
Application Process and Timeline:
Now: Actively accepting applications
December If you meet the requirements, you will receive an invitation to complete Pre-Recorded Video Interview
December - January: 2nd round interviews & offers extended
As an intern at Blue Shield of California, you will:
Participate in impactful projects during a 16-week internship program
Undertake a 16-week internship at 20 hours per week, curriculum designed to familiarize interns with BSC, leadership development, exposure to the healthcare industry, and more
Be invited to participate in BSC employee events and networking opportunities such as Employee Resource Groups, employee volunteer activities, and more
Your Work
In this role, you will:
Below is some information on the project this intern will be working on:
Performing validation of Payment Model reports and posting them to provider connection or SharePoint
Performing validation of Payment Model payment file and sending to Non-Claims Payment
Manage the Payment Model Operations logs, work with business teams to document new items or provide updates. Work with technical teams to obtain updates of items
Manage / triage the provider facing email boxes and track all items in our tracking spreadsheet
Auto-ApplyLead Business Process Consultant
Los Angeles, CA job
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.
**Position Purpose:**
Lead Business Process Consultant provides management support and strategic guidance and expertise to business case development for enterprise level initiatives across many functional areas and leads larger scale, complex, cross-functional initiatives. Drives strategic recommendations for portfolio planning with an emphasis on proactive solutions. Involved in team level development activities, such as training, mentoring, and tracking department metrics.
+ Mentors junior team members on duties and responsibilities with supervision from leadership. Leads all levels of staff who are responsible for initiatives included in the companies operating plan in order to support their success, development and effective completion and communication of their initiative
+ Oversee the pipeline of business cases and prioritize them based on strategic value, interdependencies, risk appetite, and available capacity.
+ Ensure consistent methodology and rigor in business case development across all teams, providing quality assurance and coaching to Senior Business Process Consultants. Ensures that all approved business cases are transitioned to initiatives (both documentation and clear responsibilities for each initiative) and tracks ROI for launched projects and initiatives.
+ Leads engagement and communications with senior and executive stakeholders, translating business pain points into strategic recommendations and ensures successful execution towards plan.
+ Coordinates proactive collaboration across cross-functional teams to identify and proactively respond to stakeholder business problems.
+ Leads larger scale, cross-functional initiatives that are intended to drive performance improvement, financial gains, customer satisfaction and improved compliance.
+ Provides strategic and policy guidance on assigned initiatives so that all processes are considered for maximizing effective implementation and results.
+ Organizes work teams, drives consensus and ensures end to end policy/process integrity to accomplish project work: including identification and confirmation of participants, consistent work team engagement and productivity, meeting facilitation, consensus building, recommendation documentation and implementation oversight.
+ Assists functional and project leaders in areas as needed such as facilitation, analysis, process mapping, brain-storming, project management issues, etc.
+ Writes and delivers communication to all levels of organization to ensure support, awareness and effectiveness of process improvement initiatives.
+ Provides other related support as needed to improve the performance of the business.
+ Performs other duties as assigned.
+ Complies with all policies and standards.
**Education/Experience:**
Bachelor's Degree in a related field or equivalent experience required
Master's Degree in a related field preferred
7+ years experience managing, leading projects within a consulting, healthcare, and or related sectors required
**Licenses/Certifications:**
Certified Project Management Professional (PMP)-PMI preferred
Process quality certification preferred
This position is remote within the state of California. Candidates must reside within the state of California in order to be considered. Onsite meetings as need required.
Pay Range: $105,600.00 - $195,400.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Clinical Coding Analyst, Experienced
Los Angeles, CA job
Your Role
As a Clinical Coding Analyst-Experienced, specializing in code governance, you will play a pivotal role in ensuring coding standards, compliance, and best practices across development teams. Your responsibilities will include implementing and maintaining a code governance framework, conducting code reviews, optimizing development workflows, and ensuring adherence to industry standards. You will collaborate with cross-functional teams to establish coding guidelines, automate governance processes, and enhance overall software quality and security. Your expertise will drive efficiency, consistency, and compliance in coding practices, supporting scalable and maintainable solutions.
Your Knowledge and Experience
Requires a minimum of an AA degree; Bachelors' degree preferred
AHIMA Certified CCS
Preferred certification as CSS-P
Possess deep technical abilities
Work history in one of more of the following: 2 to 3 years of Provider billing experience in a lead, supervisory or management role; or 1 to 2 years in a payor environment working directly with payment quality and accuracy in a claims processing, providing contracting or audit capacity or; 1 to 2 years in a compliance or audit function within a health care system
Requires broad theoretical job knowledge typically obtained through advanced education
Intermittent proficiency in Microsoft Excel, Word and Powerpoint
Your Work
In this role, you will:
Provide expert input to quarterly and annual industry standard code maintenance for multiple systems
Research and prepare benefit files using industry standard codes that meet the intent of member benefit language and/or contracts, and regulatory mandates set forth by the state or federal agencies
Develop payment policies based on industry or content expert-supported research
Provide problem management recommendations on correct application of payment and benefits based on industry and internal research
Conduct research and provide recommendations on industry standard editing for appropriate application in the current system in accordance with Blue Shield of CA payment policies and regulatory guidelines
Collaborate with cross-functional departments to implement code governance framework
Auto-ApplyDirector, Provider Services - Relations
Long Beach, CA job
Your Role
Reporting to the VP, Network Operations, the Director, Provider Services - Relations, Blue Shield of California and Promise Health Plan (BSCPHP), is responsible for creating and maintaining high integrity relationships with risk-baring medical providers, hospitals and health systems in their assigned region to enable BSCPHP to become the health plan of choice. The outcome of being the ideal partner for our providers will be to materially improve cost, quality, maintain compliance, service and together grow membership in service to our communities across BSCPHP business. The Director will lead in a highly matrixed environment across multiple internal business teams to provide strategic alignment, business planning, and effective execution of the business plans for all providers in their region for BSCPHP business as well as partner with all lines of business as they impact our Provider Network.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Knowledge and Experience
Requires a college degree or equivalent experience. Master's degree is preferred
Requires 10 years prior relevant experience in Provider Relations or healthcare network contracting
Requires 6 years of management experience and must be comfortable operating in a matrixed/collaborative environment
Minimum 5 years of direct Medicare and Medi-Cal experience with a Managed Care Organization (MCO) preferred
Previous experience in management of process analysis and improvement
Experience in the development of policies and procedures pertaining to Network Management
Strong experience and orientation to the quadruple aim coupled with knowledge of markets, sales, operations, product development, network management, clinical operations, finance, regulatory issues and compliance
Able to collaborate and work strategically in a team setting with various professional, technical, and administrative staff, integrating resources in a timely and organized manner
Comprehensive knowledge of managed care risk contracts and the operational requirements involved in managing a provider network
Outstanding verbal and written communication abilities, with demonstrated effectiveness when engaging executive leadership
Demonstrated ability to build enduring, trustworthy relationships and effectively interact across all organizational levels, both internally and externally
Ability to lead and manage significant culture change. Demonstrated experience with change and organization management; possess a performance driven management style
Strong leadership skills, including excellent interpersonal, communications, problem solving and negotiating skills
Ability to think strategically while at the same time drive operational performance
Proven project management experience applying industry methodologies and practices
Technologically savvy and able to utilize information systems and Office software effectively
Proven ability to mentor and coach leaders in their respective teams
Your Work
In this role, you will:
Lead the Provider Relations team which serves as the primary liaison between BlueShield and Blue Shield Promise Health Plan and the contracted provider networks upholding transparency, integrity, and reliability in interactions with both internal and external stakeholders
Oversee the management of provider concerns, including but not limited to contract interpretations, claims discrepancies, eligibility and capitation payment issues, credentialing challenges, service area changes, rate load corrections, retroactive member assignments, provider terminations, member moves and third-party disputes
Develop and implement an operations engagement strategy that incorporates statewide Joint Operations Meetings, inclusive of Medi-Cal requirements, and includes interaction with provider leadership. The aim is to support provider satisfaction with Blue Shield, encourage provider wellness, and maintain operational performance in areas such as access to care, member experience, affordability, and sustainability
Manage structured processes for claims disputes and appeals, driving research, root cause analysis, and corrective action plans to prevent recurring issues
Deliver expert insight and guidance for strategic and operational initiatives impacting Provider Relations, driving effective execution of implementation tasks within the team's scope
Provide effective and detailed thought leadership to inform the Blue Shield Provider Engagement Model working with the Performance Enablement Team
Work collaboratively with Provider Partnerships and the Regional Medical Directors, along with other internal provider-facing partners, to execute an overall strategic engagement strategy
Identify and implement process improvement as it pertains to provider operations, contract and regulatory compliance, efficient relationship management and other areas
Establish operational Key Performance Indicators to assess the effectiveness and performance of the Provider Relations team. Define baseline metrics, set measurable targets, and drive achievement through ongoing process improvement
Assess regulatory, government, or organizational mandates to ensure Blue Shield and Blue Shield Promise Health plans comply with all requirements. Work collaboratively with various departments to maintain internal compliance with regulations by leading workgroups and taskforces
Build and lead a high-performing team that meets all operating goals, including cost of health care, clinical quality improvement, regulatory compliance, administrative costs and employee engagement
Foster a culture of innovation and creativity to enable Blue Shield of California to meet changing market conditions and strategy
Promote and model a collaborative and partnership-oriented culture by cultivating strong relationships with internal stakeholders to achieve collective success
Auto-ApplyPer Diem Pharmacy Technician
Gardena, CA job
Explore opportunities with CPS, part of the Optum family of businesses. We're dedicated to crafting and delivering innovative hospital and pharmacy solutions for better patient outcomes across the entire continuum of care. With CPS, you'll work alongside our team of more than 2,500 pharmacy professionals, technology experts, and industry leaders to drive superior financial, clinical, and operational performance for health systems nationwide. Ready to help shape the future of pharmacy and hospital solutions? Join us and discover the meaning behind Caring. Connecting. Growing together.
As a per diem Pharmacy Technician you will assist in various pharmacy activities under the supervision of a licensed pharmacist. Your responsibilities will include preparing, delivering, and restocking medications; performing order entry; procuring drugs; billing. You will carry out your job duties according to written procedures and guidelines based on pharmacy standards and regulatory requirements.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
* High school diploma or equivalent
* Active applicable state Pharmacy Technician license in good standing
* Recent work experience as a Pharmacy Technician, ideally in a hospital or outpatient setting
* Proficiency with pharmacy software
Preferred Qualification:
* PTCB/CPhT
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $16.00 to $27.69 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.