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<p>Salary Range:&nbsp;&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role is ensures that UM practices and supporting documentation are compliant with all regulatory requirements. &nbsp;The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up.&nbsp; This position actively participates in development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position will focus on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and create reports on audit findings, as well as make recommendations, to submit to the department's Quality Assurance Team and UM Management.</p><h4>Duties</h4><p>Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines.</p><p>Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions.</p><p>Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation.&nbsp;</p><p>Works with department leadership to assess for all opportunities related to quality improvements.&nbsp;</p><p>Compiles and presents quality report cards that measure adherence to quality and regulatory compliance.&nbsp;</p><p>Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts.</p><p>Serves as a consultant to the organization's Compliance team on an ad hoc basis.</p><p>Performs other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's DegreeMaster's Degree in Nursing<h4>Experience</h4><p>Required:&nbsp;<br>At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. &nbsp;Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation.</p><p>Preferred: &nbsp;<br>Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. &nbsp;Background in teaching and/or clinical education.</p><h4>Skills</h4><p>Required:&nbsp;<br>Superior verbal and written communication skills.&nbsp;</p><p>Advanced computer proficiency in both Microsoft Word and Excel.&nbsp;</p><p>Strong analytical and team building skills.&nbsp;</p><p>Ability to work independently and be self-directed.&nbsp;</p><p>Ability to work effectively with diverse team members.&nbsp;</p><p>Strong problem-solving skills.&nbsp;</p><p>Ability to multitask and streamline day-to-day operations.&nbsp;</p><p>Ability to translate regulatory requirements into auditable tools.&nbsp;</p><p>Preferred:</p><p>Proven ability to lead successful performance improvement projects.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul>

L.A. Care Health Plan

Utilization Management Clinical Quality Nurse Reviewer RN II

<p>Come care with us at West Coast University! As a Nursing Faculty member for a certified Great Place to Work, you will guide nursing students to do more than change their own lives – you will help change the lives of every patient they treat throughout their career in healthcare. &nbsp;At West Coast University you will have the opportunity to share your success story with the next generation of nurses as a key member of our student-centered, innovative community!</p><p><strong>You will make an impact by: &nbsp;</strong></p><ul><li>Serving as a mentor, role model and facilitator who provides guidance and academic support for students.</li><li>Demonstrating enthusiasm for teaching, the teaching/learning process and for individual students.</li><li>Applying your skills and experience to your assigned teaching schedule.</li><li>Participating in and contributing to assessment activities of courses/curriculum and programs via a continuous improvement plan set forth by the University.</li><li>Regularly contributing to improvement of class materials and syllabi within prescribed shared governance culture.</li><li>Utilizing a variety of teaching methodologies to instruct students, always with intent to facilitate observable evidence of student fulfillment of prescribed learning outcomes.</li><li>Maintaining scholarly activities.</li><li>Participating in professional growth and service in accordance with university policies.</li><li>Advancing our commitment and focus on the students we serve, and their success as healthcare professionals.</li><li>Fully leveraging our innovative technologies and resources, such as our Simulation and Innovation Labs.</li><li>*If working with students in a Clinical setting you will:<ul><li>Assume complete responsibility for students in clinical facilities.</li><li>Clarify clinical expectations with students.</li><li>Clarify student placement and expectations with clinical facility staff.</li><li>Utilize care planning time to direct students to available resources needed for clinical preparation.</li><li>Assess student knowledge and skill level to ensure safety and optimal care to patients.</li><li>Utilize pre- and post- conference to allow students an opportunity to share learned experiences, ensuring clarity of the correlation between &nbsp;weekly theory content with clinical objectives and experiences.</li><li>Provide feedback of clinical performance immediately after observation of event and of overall performance at midterm and end of semester.</li></ul></li></ul><p><strong>Your Experience Includes: &nbsp;</strong></p><ul><li>Working knowledge of Microsoft Office Suite Products, especially Outlook, Word, PowerPoint and other MS office products as needed.</li><li>Working with online learning management systems to further engage the student learning process.</li><li>Compliance with state, federal and local laws/regulations relating to programs, governmental compliance, and other regulatory standards such as state Board of Nursing.</li><li>Clinical RN - Must have a minimum of two (2) year’s prior experience as a registered nurse providing direct patient care and have a minimum of one year experience in the field in which they teach.</li></ul><p><strong>Education:</strong> Education and experience must align with state regulations and comply with the rules and regulations of state authorization agencies.</p><ul><li>Master’s degree in nursing</li><li>Professional nurse licensure required.</li></ul>

West Coast University

Nurse Faculty

<p>Salary Range:&nbsp;&nbsp;$60,778.00&nbsp;(Min.) -&nbsp;$75,950.00&nbsp;(Mid.) -&nbsp;$91,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Customer Solution Center Appeals and Grievances (A&amp;G) Specialist II &nbsp;will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. This position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. &nbsp;The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.</p><p>The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.</p><h4>Duties</h4><p>Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.</p><p>Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment.&nbsp;</p><p>Ensures integrity of A&amp;G database by thorough, timely and accurate assignment of cases. &nbsp;Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.&nbsp;</p><p>Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.</p><p>Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. &nbsp;Recommends opportunities for improvement</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Bachelor's Degree<h4>Experience</h4><p>Required:</p><p>At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.&nbsp;</p><p><br>Experience working with firm deadlines, able to interpret and apply regulations. &nbsp;</p><p>At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs. &nbsp;</p><p>Knowledge of Medical terminology and strong advocacy experience.</p><h4>Skills</h4><p>Required:<br>Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills. &nbsp;</p><p>A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.<br><br>Proficient in MS Office applications, Word, Excel and Power Point.&nbsp;</p><p>Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.&nbsp;</p><p>Preferred:<br>Proficient in MS Office applications, Access, Visio.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p>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.</p><p><br>L.A. Care offers&nbsp;a wide range of benefits including</p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul>

Customer Solution Center Appeals and Grievances Specialist II (ALD)

<p>At West Coast University, we share a passion for students and transforming healthcare education! As a faculty member for a certified Great Place to Work, you willjoin a collaborative, student-centric culture valuing academic integrity, mutual respect, student learning, service, responsiveness, innovation, diversity, and stewardship. As a part of this team, you will guide students to do more than change their own lives – you will help change the lives of every patient they care for throughout their career.&nbsp;</p><p><strong>You will make an impact by:</strong></p><ul><li>Providing program-specific expertise and is actively engaged in relevant department initiatives. Supporting University, Campus, and/or departmental goals to assure compliance with programmatic accreditation and/or licensure, internal consistency, and graduate outcomes that meet student learning, workplace, and placement expectations. </li><li>Providing professional leadership and support, and serving as an educator, role model, mentor and facilitator. </li><li>Creating an educational environment which fosters innovation, responsiveness, and accountability. Focuses extensively on facilitating student learning associated with prescribed course and program learning outcomes. </li><li>Actively and substantively participating in assessment of student learning activities to maximize the potential for students to learn what is necessary to meet prescribed outcomes. </li><li>Vigorously upholding a culture of academic integrity.</li></ul><p><strong>Your Experience Includes:</strong></p><ul><li>Greater than 3 years of clinical experience</li><li>Experience teaching in a PA program or Medical School preferred.</li><li>Experience with ARC-PA accreditation in provisional and/or maintenance phase preferred. </li><li>Non-doctoral faculty: doctoral degree or willingness to enter and complete a doctoral program</li></ul><p><strong>Education:</strong></p><ul><li>Master’s degree, Physician Assistant; or</li><li>Master’s degree, or higher, in health-related field</li></ul><p>If a non-clinician scientist (Scientist Position):</p><ul><li>Doctorate degree in health- or social-science related field.</li><li>Minimum of three years teaching/research/clinical experience.</li></ul><p>Preferred:</p><ul><li>NCCPA certified Physician Assistant or Board certified allopathic or osteopathic physician</li><li>Texas PA license (or eligible) or MD / DO license or eligible for licensure in Texas</li></ul><p>West Coast University is proud to be an equal opportunity employer. We celebrate diversity and are dedicated to creating an inclusive environment for all associates. If you feel that this role could make you excited to come to work and you can envision yourself working at our organization, please apply! West Coast University is a place where everyone can grow.</p>

Assistant Professor, Physician Assistant

<p>Job Description:</p><p>POSITION SUMMARY</p><p>The Enrollment Counselor position at Pacific Oaks supports all recruitment, admissions, and advising efforts at the college. Additionally, it helps with activities by handling communications, information and paper flow with prospective and admitted students. The successful candidate will be an articulate, organized, results driven, a dynamic and enthusiastic leader, and a team player.</p><p>This position is located in Pasadena and reports directly to the AVP of Admissions.</p><p>ESSENTIAL JOB FUNCTIONS:</p><ul><li>Provide excellent customer service to prospective students throughout the full admission recruitment process</li><li>Meet daily expectations for outbound dials, set campus consultations</li><li>Meet with prospective students to counsel on completing Admissions requirements, discusses academic programs, admission options, and financial aid opportunities and conducts campus tours.</li><li>Meet/exceed Admission benchmark goals</li></ul><p>JOB FUNCTIONS:</p><ul><li>Availability to work evening shifts and a rotating Saturday shift as needed</li><li>Follow up with prospects and applicants by phone and written correspondence.</li><li>Plan and coordinate on-campus Information Sessions and Open Houses for prospective students</li><li>Regularly attends the school department staff meetings</li><li>Assist new and continuing students with registration process</li><li>Follow up with admitted/current students to ensure they maintain part-time/full-time status</li><li>Liaise with corresponding departments to support the admissions team</li><li>Ensure students meet with Faculty Advisors to outline program completion plans</li><li>Track and document all communication with Inquiries, applications and students through Salesforce and Campus Vue</li></ul><ul><li>Contributes to a work environment that encourages knowledge of, respect for, and development of skills to engage with those of other cultures or backgrounds.</li></ul><ul><li>Performs other duties as assigned.</li></ul><p>REQUIRED KNOWLEDGE, SKILLS &amp; ABILITIES:</p><ul><li>Sales knowledge, skill and experience; in addition to person-to-person account management experience</li><li>Consultative approach to answering questions, addressing concerns and assisting with enrollment decisions</li><li>Highly accountable to monthly goals, performance expectations</li><li>Ability to establish rapport and build relationships with prospective students</li><li>Demonstrated ability to multi-task, organize, manage time while meeting and/or exceeding expectations and goals</li><li>Demonstrated ability to work independently and collaborative with little supervision in an fast-paced environment</li></ul><p>PREFERRED KNOWLEDGE, SKILLS &amp; ABILITIES:</p><ul><li>Keep current on CFP, HD and SOE programs information and State licensure requirements</li><li>Understanding of and experience with non-traditional student populations</li><li>Keeps current on credential program information and the schools credentialing requirements&nbsp;</li><li>Excellent written and verbal communication skills; accuracy and attention to detail</li><li>Possess professional interaction, personal networking and constituency building skills; and possess interesting, dynamic, articulate, credible and fluid group presentation skills</li><li>Ability to meet annual inquiry plans as recorded weekly</li><li>Inquiry generation and effective inquiry follow-up capability</li><li>Self-directed and highly motivated, high activity action taking recruiting students</li><li>Executing continuous high volume contact, mapping out efficient travel logistics, coordinating and conducting events, sustaining high levels of diverse activity and multi-tasking under strict deadlines</li><li>Knowledge of the education industry</li><li>Demonstrated, consistent results producer.</li><li>Enrollment, academic advising knowledge/experience</li><li>Ability to guide prospective students through the university admissions process and overcome any obstacles that may arise</li><li>Excellent written and verbal communication required</li><li>Excellent ability to speak in public and conduct presentations for large groups and one on one.</li><li>Possess a positive and enthusiastic attitude to promote a healthy work environment.</li><li>Ability to travel evenings and weekends; possess valid driver’s license</li><li>Ability to work evenings/weekends and have a flexible schedule</li><li>Self-motivated, goal-oriented, results driven</li></ul><p>REQUIRED EDUCATION:</p><ul><li>Bachelor’s degree required with minimum of 1 years' experience in college admissions, recruitment or sales preferred; OR a minimum of 5 years' history in an enrollment/admissions position in nontraditional higher education recruitment;</li></ul><p>PREFERRED EXPERIENCE:</p><ul><li>Minimum 1-2 years’ experience in college admissions, recruitment or student services preferred.</li><li>Experience working with non-traditional students</li><li>Sales Knowledge or Sales Experience</li></ul><p>PHYSICAL REQUIREMENTS (based on a typical week):</p><p>Key:</p><p>C&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Constant(over 66% of time)</p><p>F&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =Frequent(34%-66% of time)</p><p>O&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Occasional(1%-33% of time)</p><ul><li>Lifting/carrying under 10 lbs. – O</li><li>Pushing/pulling under 10 lbs. – O</li><li>Reaching outward – O</li><li>Sitting – C</li><li>Standing – O</li><li>Bending – O</li><li>Walking on normal surfaces – F</li><li>Typing/keyboarding/ten-key – C</li><li>Fine handling/grasping – O</li><li>Repetitive motion (hands) – O</li></ul><p>Compensation &amp; Benefits</p>This opportunity is budgeted at $20.00-21.50 base compensation. Additional compensation factors may impact total compensation. To learn more about our competitive benefits and additional rewards, including generous paid time-off, medical and dental insurance coverage, life and disability insurance, retirement plan with employer contribution, multiple flexible spending accounts, tuition reimbursement, click the link below.<p><a href="https://www.pacificoaks.edu/about/careers-pacific-oaks/" target="_blank">https://www.pacificoaks.edu/about/careers-pacific-oaks/</a></p><p>Pacific Oaks is an Equal Opportunity Employer.</p><p>Pacific Oaks participates in E-Verify and verifies identity and employment eligibility of all persons hired.<br></p><p><i>The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. Pacific Oaks offers equal employment opportunities to all persons without regard to race, color, ethnicity, religion, sex, sexual orientation, national origin, age, marital status, physical or mental disability, parental status, housing status, source of income or military status, in accordance with applicable federal, state and local EEO laws.</i></p>

25 Healthcare / Pharmacy Jobs in Brea, CA, USA