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Manager, Claims Integrity Provider Remediation (ALD)

Job Category:  Management/Executive
Department:  Claims Integrity
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  7186

 

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 Manager, Claims Integrity Provider Remediation is responsible for development and implementation of methods to accurately and timely review provider escalations, inquiries, logs or other submissions.  This position will work to best coordinate efforts across the Claims Integrity departments ensuring the highest level of quality responses to all stakeholders.  This position will manage a team dedicated to maintaining constant communication, consistent quality, and root cause identification and resolution for provider cases. This position manages all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Manages provider escalations, inquiries, logs or additional submissions to accurately and timely respond to all stakeholders.  Monitors inventory to ensure prompt resolution while maintaining all regulatory requirements and timely escalation of areas close to non-compliance.  Oversees preparation of summaries and reports for related tasks for both internal and external teams.

 

Oversees team in day to day operations to include timely and accurate response on all Provider Inquiries while assisting with resolution of higher complex cases.  Meets with team regularly to detail project assignments, ensure accountability, review quality and work metrics. Manages team development and direct support to include training, performance standards, and process improvements.

 

Provides subject matter expertise, meets with Director and other Management to collaborate on provider meetings, ensuring all communications are clear, concise and accurate.  Applies Medi-Cal and/or Medicare policies and procedures within healthcare operations.   Stays abreast of all regulatory and/or contractual changes and the impact of these changes to provider escalated issues.

 

Supports the Director and other Management with development of department policies and procedures, workflows, training documents, etc.  Consults with Claims Integrity team in making recommendations to management on operational issues.

 

Fosters and maintains a great place to work by communicating clear roles and responsibilities and building successful working relationships across Claims Integrity.

 

Manages 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.

 

Performs other duties as assigned.

Education Required

Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Experience


Required:
At least 5-7 years experience related to Claims, Appeals and grievances, disputes, etc.

 

At lease 3-4 years of supervisory/Management experience.

 

Preferred:
Provider Dispute Resolution experience.

Skills

Required:
Extensive knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.

 

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail.

 

Knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.

 

Excellent interpersonal, verbal, and written communication skills.

 

Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.

 

Must be able to present findings to various levels of management, and including stakeholders, across all organization.

 

Preferred:
Ability to review claims in 360-degree approach.

Licenses/Certifications Required

Licenses/Certifications Preferred

Certified Professional Coder (CPC) or other equivalent Coding Certification

Required Training

Additional Information

 

This position is a limited duration positon. 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)

 

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, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Medical, Claims, Medicare, Medicaid, Medical Coding, Healthcare, Insurance

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