Appeals & Grievance Compliance Analyst
4 weeks ago
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 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.
The Customer Solution Center (CSC) Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for the following end-to-end processes within CSC (i.e. Enrollment processing timeliness and accuracy of loading members, timeliness of I.D. Card and member materials, outbound health risk assessment (HRA) calls for Seniors and People with Disabilities (SPD) and Cal MediConnect (CMC) plus HIF for L.A. Care Medi-Cal Direct program (MCLA), call documentation and categorization, service authorization request and coverage determination , Appeals and Grievances across all lines of business). This position is responsible for the ongoing progression and maintenance of CSC's compliance program efforts, including, but not limited to, policy and procedure development, training and education initiatives, and compliance programmatic developments and enhancements.
This position will complete targeted, focused and random audits related to member interactions and outcomes to ensure all elements are compliant. These results will be provided to management with recommendations and/or corrective actions required to remediate the deficiencies. This position will be responsible for the regulatory obligations for each line of business and their governing bodies; California Department of Health Care Services (DHCS), Department of Public Social Services (DPSS), Centers for Medicare and Medicaid Services(CMS), LACC - CalHers, and National Committee for Quality Assurance (NCQA) along with review and analysis of regulatory requirements for all product lines The position will take lead in all of the audit situations and be prepared to present and report full findings and ensure action plans are created, executed, and verified through reconciliation of end to end on all regulatory functions.
DutiesAudit readiness: Performs audit procedures for Customer Solution Center departments to ensure readiness; including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting business unit processes and procedures. Conducts interviews, reviews documents, develops and administers surveys, composes summary memos and prepares working papers. Identifies, develops, and documents audit issues and recommendations using independent judgement concerning areas being reviewed. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to Customer Solution Center management. Collaborates with business units in audit universe preparation and validation. Assists in document preparation for regulatory and internal audits.
Regulatory compliance: Works closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes. Collaborates with internal Subject Matter Experts (SMEs) to understand Customer Solution Center regulatory processes and assists with getting to the root cause of identified deficiencies. Evaluates policies and procedures with applicable regulations/guidelines and provides recommendations to management for continuous process improvements.
Collaborates with Customer Solution Center Business Analyst to track, trend, and analyze results of Quality Assurance (QA) scorecards for training and quality improvement.
Perform other duties as assigned.
Duties ContinuedEducation Required
Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.Education Preferred
Experience
Required:
A minimum of 5 years of experience in regulatory auditing (Appeals & Grievances, Call Center, Enrollment) in a healthcare environment required.
Previous experience with Medi-Cal and Medicare in a managed care environment.
Preferred:
Tableau experience.
SkillsRequired:
Advanced computer proficiency, Word, Excel; and Access is required.
Strong analytical and team building skills.
Ability to work effectively with diverse team members.
Ability to formulate recommendations to improve quality and service delivery, and develop effective system and process improvements.
Ability to multi-task and streamline day-to-day operations.
Ability to track and trend and create regulatory reporting.
Strong interpersonal and organization skills and is expected to work independently within the department's established guidelines, policies and procedures.
Licenses/Certifications RequiredLicenses/Certifications Preferred
Required Training
Physical Requirements
LightAdditional Information
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.
-
Grievance and Appeals Operations Manager
1 week ago
Los Angeles, California, United States Insight Global Full timeJob OverviewThe Grievance and Appeals Operations Manager is tasked with overseeing and guiding the team responsible for the reception, investigation, resolution, monitoring, analysis, and reporting within the Grievances and Appeals division. This role is pivotal in steering the efforts of the department by ensuring comprehensive investigations are conducted...
-
Appeals and Grievances Specialist
2 minutes ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment.This position will provide resolution of complaints in compliance with regulatory requirements, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, 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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, 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...
-
Appeals and Grievances Specialist
2 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Service Representative II plays a critical role in ensuring that member and provider complaints and appeals are resolved in a timely and fair manner. This position requires strong independent judgment, conflict resolution, and persuasion skills to resolve complex issues.Key ResponsibilitiesInvestigate and resolve administrative...
-
Regulatory Compliance Analyst II
1 week ago
Los Angeles, California, United States Insight Global Full timeJob OverviewThe Regulatory Compliance Analyst II plays a crucial role in ensuring adherence to regulatory requirements by formulating auditing methodologies, overseeing the compliance framework, executing focused audits, and offering suggestions for remedial actions. In this capacity, you will be responsible for developing a corrective action strategy for...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $60, Min.) - $75, Mid.) - $91, 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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.)PLEASE NOTE: This position will work Sunday thru Thursday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Tuesday - Saturday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Wednesday - Sunday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States Preferred IPA of California Full timeJob OverviewPositions available for a Quality Assurance Nurse and a Compliance Specialist. QUALITY ASSURANCE NURSEOBJECTIVE:The Quality Assurance Nurse plays a crucial role in collaboration with the Medical Director, the VP of Clinical Policy, and the Quality Management Committee to develop, implement, and enhance the Quality Management Program. This...
-
Medical Director, Clinical Leadership Expert
4 days ago
Los Angeles, California, United States UCLA Health Full timeKey Clinical Leadership RoleTake on a pivotal clinical leadership position within a dynamic health organization, driving the delivery of high-quality, cost-effective care for Medicare Advantage members. Leverage your expertise to new heights at New Century Health Plan.Reporting to the Chief Medical OfficerYou will play a crucial role in leading clinical...
-
Lead Compliance Analyst
1 week ago
Los Angeles, California, United States State Revenue Office Full timeWe are currently seeking qualified candidates for the position of Lead Compliance Analyst within the Forensics and Information Management Branch of the Corporate Services Division. Position Overview This role encompasses the opportunity to engage in complex research and analytical projects that pertain to adherence to State legislation, organizational...
-
Compliance and Credentialing Specialist
4 days ago
Los Angeles, California, United States KHEIR Center Full timeJob SummaryWe are seeking a highly skilled Compliance and Credentialing Specialist to join our team at the Kheir Center. As a key member of our Compliance and Credentialing teams, you will play a critical role in ensuring our organization meets all necessary laws, regulations, and policies.The ideal candidate will have a strong background in healthcare...
-
Medical Director, Clinical Leadership Expert
3 days ago
Los Angeles, California, United States UCLA Health Full timeKey Clinical Leadership RoleTake on a pivotal clinical leadership position within a dynamic healthcare organization. Drive the delivery of high-quality, cost-effective care for Medicare Advantage members. Elevate your expertise and contribute to the success of New Century Health Plan.Reporting to the Chief Medical OfficerYou will play a critical role in...
-
Compliance Analyst for Financial Operations
7 days ago
Los Angeles, California, United States augmentjobs Full timeJob OverviewPosition Title: Financial Compliance AnalystPosition Summary: We are looking for a diligent and detail-focused Financial Compliance Analyst to become a part of our compliance division. In this role, you will be tasked with ensuring that our organization adheres to regulatory standards, policies, and procedures. Your responsibilities will include...
-
Regulatory Compliance Financial Analyst
7 days ago
Los Angeles, California, United States augmentjobs Full timeJob OverviewPosition Title: Financial Compliance AnalystPosition Summary: We are looking for a detail-oriented and diligent Financial Compliance Analyst to become a vital part of our compliance division. In this role, you will play a crucial part in ensuring that our organization adheres to all relevant regulatory standards, policies, and procedures. Your...
-
Business Analyst III
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, 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...
