Advisor Provider Network Management

Job Category: Provider Relations

Department: Provider Network Management

Location:

Los Angeles, CA, US, 90017

Position Type: Full Time

Requisition ID: 9340

Salary Range: $126,821.00 (Min.) - $168,037.00 (Mid.) - $209,255.00 (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 in five health plans, 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.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Advisor Provider Network Management works closely with key stakeholders in areas of Claims, Recovery, Configuration, Provider Dispute Resolution, and Provider Network Management to assess processes, procedures, policies and conduct end-to-end root cause analysis to enhance and improve outcomes and remediate issues related to provider reimbursement.

This position utilizes up-to-date knowledge of current trends and issues in healthcare, national and statewide standards and regulations, policies and procedures as well as have a solid understanding of the legal implications of Federal and State regulatory guidelines pertaining to claims processes. Applies this knowledge to the development of exceptional enhancements to current operations affecting provider dispute outcomes.

This position will serve as a liaison between partnering departments i.e. Payment Integrity and Claims Compliance. This position works to ensure claims are being processed per regulatory guidelines as well Medi-Cal guidelines and contractual agreements.

Duties

Conduct root cause analysis of enterprise current state relating to provider issues, inclusive but not limited to provider claims payment, configuration, payment integrity, authorization, member exception flag relating to Letter of Agreement (LOA), and cap deduct process. Root cause analysis to include development of remediation plan and managing the end-to-end enhancement to improve future outcomes.

Lead in discovery of operational issues across enterprise, meet and confer with business unit leads to document current state, identify gaps and necessary fix, present remediation plan/options to leadership, document future state, lead implementation of identify fixes, and monitor future state once implemented.

Develop reports, analyzes data and provides presentation on status of areas of responsibilities on an as needed basis in support of department operations.

Meet with key functional areas on remediation plans for their area and address questions with these key stakeholders to address new or ongoing issues.

Performs high quality review of payable and post payment claims in a rapidly changing work environment. Perform full review of files submitted by provider and AR dispute packages.

Document issues, construct a remediation plan and path to remediate.

Performs 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:
At least 6-8 years claims processing, provider dispute resolution or claims recovery experience.

Prior experience working with PDR’s, third party liability and coordination of benefit claims.

Skills

Required:
Solid understanding of complex contractual terms and conditions as well as ability to interpret Health Plan benefit documents.

Good understanding of regulatory requirements pertaining to Medi-Cal and Medicare billing and payment guidelines.

Excellent written and verbal communication skills.

Ability to work with diverse groups and teams.

Strong analytic skills.

Excellent organizational skills.

Proficiency with Microsoft Office applications (Word, Excel, Access, PowerPoint).

Understanding of the dynamics and relationships between and among federal and state regulators/agencies, physician associations, hospital associations, community clinic associations, and public health care systems.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

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)

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, it's expected that all employees wear a mask in areas where physical distancing cannot be managed.