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October 26, 2015 | VOLUME 22 | NUMBER 41

T O P S T O R I E S

Insurance Commissioner Says Aetna Rate Hike Is ‘Unreasonable’ Jones critical of premium increase for small businessesCalifornia insurance commissioner Dave Jones described Aetna’s fourth quarter rate hike for small businesses as an “unwarranted and unreasonable” increase that will saddle businesses with more than $5 million in new premiums. The state Department of Insurance (DOI) estimates that Aetna’s 3.4% rate hike for the fourth quarter brings its annual average increase to 27.4%. Jones said the premium hikes will affect more than 40,000 employees in the state and will cost businesses an estimated $5.5 million. “Small businesses are the lifeblood of California’s economy,” said Jones. “Small businesses simply cannot afford unwarranted and unreasonable increases in health insurance costs nor can their employees.” Aetna said its rate increase was warranted and based on “actuarially sound” data and estimates. “While rate increases are never easy, our rates are based on actuarially sound data and a reasonable projection of future costs, which will impact approximately 40,300 customers,” said Aetna spokesperson Anjie Coplin. “As required by law, our assumptions and rates were reviewed by an independent actuary, who certified them as reasonable.” Coplin added that “increases in medical costs and utilization for our members enrolled in our small group plans continue to exceed the rate at which we’ve been able to increase premiums” and that Aetna expects underlying medi-cal costs to increase 8.6% next year. She said Aetna’s projected Medical Loss Ratio for 2015 is 82%, which exceeds the minimum federal requirement of 80% for small group plans. This isn’t the first time Aetna has been criticized for a small group rate hike this year. In July, the state Department of Managed Health Care (DMHC) said Aetna’s estimated 12-month average premium increase of 21% for small group plans was “unreasonable” and part of a pattern. “Two-thirds of this department’s unreasonable premium rate findings have been for Aetna rate increases,” said DMHC director Shelley Rouillard. “Aetna’s pattern of unreasonable increases equates to price-gouging in today’s

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Insurance Commissioner cont. » Ten California hospitals were includ-

ed in a list of 159 Most Connected Hospitals in the U.S. compiled by U.S. News & World Report. Hospitals includ-ed on the list were evaluated on a num-ber of measures including their ability to electronically exchange patient data with other providers and allow patients to access their medical data. California hospitals on the Most Connected list are: Cedars-Sinai Medical Center in Los Angeles, Kaiser Permanente Baldwin Park Medical Center, Mills-Peninsula Health Services in Burlingame, Providence Holy Cross Medical Center in Mission Hills, Rady Children’s Hospital in San Diego, Resnick Neuropsychiatric Hospital at UCLA, Stanford Health Care - Stanford Hospital, UCLA Medical Center, UC Davis Medical Center in Sacramento, and UC Irvine Medical Center in Orange. Ohio had the larg-est number of hospitals to make the list at 23 followed by Wisconsin with 16 hospitals and Pennsylvania with 12 hospitals.

» Santa Clara County supervisors have hired Boldt Construction to take over construction of Santa Clara Valley Medical Center. County super-visors chose Boldt Construction to replace Turner Construction Company, a builder that had been working on the hospital for nearly five years and was fired in September. According to a report from NBC Bay Area, the new contractor will complete construction of the 168-bed hospital that was origi-nally scheduled to open in September.

market. I strongly encourage small employers subjected to these unreasonable increases to explore more affordable health coverage options.” California state insurance officials have the authority to reject premium increases for auto and property insurance but not for health insurance rate hikes. A ballot measure that would have given the state insurance commissioner authority to reject health insurance premium increases - Proposition 45 - was rejected by voters in November 2014 by a 59% to 41% margin. In a related matter, Blue Shield of California has agreed to limit or exclude rate increases for some policyholders in 2016 and 2017 as part of an agreement allowing it to acquire Care1st Health Plan. As part of its agreement to approve the purchase, the DMHC will require Blue Shield to limit premium increases for small, group, individual, and family plans in 2017 and to not impose a rate increase for small group plans in the second quarter of 2016. The DMHC said it was concerned about Blue Shield’s projected profit tar-gets, which “warranted the department’s action to find a solution with the plan that will protect consumers and ensure that rates are supported.” The DMHC order will require Blue Shield to limit 2017 premium increases for individual and family plans to a 1.41% profit margin cap and to a 1.67% profit margin cap for small business plans. DMHC will also require Blue Shield to recal-culate and submit its Medical Loss Ratio estimates for 2015 and 2016. On Oct. 8, the DMHC approved Blue Shield’s $1.2 billion acquisition of San Diego-based Care1st, a Medicaid and Medicare Advantage plan with 524,000 members in California, Arizona, and Texas. —DOUG DESJARDINS

Study Shows Narrow Network Plans don’t Impact Quality of CareNumber of hospitals in network doesn’t influence quality A new study found that the number of hospitals in narrow network plans sold on Covered California does not impact the quality of care provided under those plans. The study from the California HealthCare Foundation (CHCF) and Cynosure Health Solutions titled ‘Narrow Networks: Does Limited Choice of Hospitals Affect Quality in Covered California?’ looked at a range of narrow network plans sold on the health insurance exchange. The study used clinical data on quality of care from the California Hospital Assessment and Reporting Task Force and information on premiums from Covered California. Overall, the report found the difference in quality among narrow networks was “not clinically significant” and that, in most cases, the size of a network had no impact on

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“It [the completion of the hospital] is very important for the people who need care,” said Santa Clara County supervi-sor Dave Cortese. “And we’re really constrained as long as this problem drags on.” Santa Clara County terminat-ed its contract with Turner Construction after repeated delays in construction that put the hospital opening more than one year behind schedule. Turner Construction officials said delays for the $300 million project were caused by repeated design changes requested by county officials. Santa Clara County officials hope to have the hospital open by late 2016.

» The California Medical Association (CMA) installed Steven Larson, MD, as its new president for 2015-2016 to replace outgoing president Luther Cobb, MD. Larson is an infectious diseases specialist who practices in Riverside and San Bernardino coun-ties and is currently CEO and chairman of the board for Riverside Medical Clinic. Larson also serves as a clinical professor of biomedical sciences at the University of California, Riverside School of Medicine. “I have tremen-dous respect for Dr. Larson and his abil-ity to represent the diverse physicians of California and the patients for whom we care,” said Cobb. “I have worked closely with him over the years and expect great things under his capable leadership.”

» The California Department of Public Health (CDPH) reported an increased number of two mosquito spe-

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the overall quality of care provided by a health plan. The study stated that “limited hospi-tal network structure was not seen to influence quality performance” and that any con-cerns about narrow networks should focus on access to care rather than quality of care. “While there was a difference in quality of care in health plans in different regions of the state, the size of the networks was not a factor in most instances,” said Bruce Spurlock, MD, president and CEO for Cynosure Health Solutions and lead author of the study. The study found the number of hospitals included in networks ranged from 1 to 32 with an average of 10 hospitals per network. The study noted that “while network nar-rowness has been linked to lower premiums, the research found no relationship between the number of hospitals in a network and the composite quality performance score.” Spurlock said the only link between narrow networks and quality was found in networks with between one and three hospitals, which had the lowest scores. In those cases, Spurlock said the low scores were probably due to one poorly performing hospital dragging down the overall rating. The study found that health plans in the Bay Area and Northern California had the highest scores for quality of care. The highest-rated plans with an average score of 87 were located in San Francisco County followed by San Mateo County (86.5), North Bay Counties (86.5), and Santa Clara County (85.8). The lowest-rated plans were located in Kern County (78.9), Orange County (79.9), and Eastern Counties (80.6). The study also found that individual hospital scores ranged from 77 to 92 and reflected “a fairly narrow range of performance.” It also found “a tightly bunched level of performance” among all narrow network health plans. Spurlock said the study results indicate that lower-priced narrow network plans could become more popular as price-conscious consumers drive the market. The study noted that consumers “can choose different plan products with high confidence that they will receive generally equivalent hospital care.” “In the commercial space, buyers are typically looking for plans that offer the largest number of hospitals and medical groups to provide care,” said Spurlock. “But that’s not the case with consumers who are mainly looking for lower premiums rather than more options.” He said that dynamic may change the way insurers pick and choose hospitals and health systems when building narrow networks and that insurers may begin exclud-ing higher-priced hospitals in an effort to keep premiums lower.—DOUG DESJARDINS

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cies in the state that can spread infec-tious diseases. The CDPH said that, for the first time, the yellow fever mos-quito was detected in San Bernardino and Riverside counties while the Asian tiger mosquito is now present in 14 California counties including Kern, Los Angeles, Alameda, and San Mateo. “While the risk is still low in California, infected travelers coming back to California can transmit these viruses to mosquitos that bite them,” said Karen Smith, MD, CDPH director and state public health officer. “This can lead to additional people becoming infected if they are then bitten by those mos-quitos.” The CDPH said both species of mosquito can transmit yellow fever, dengue fever, and chikungunya.

» A UC San Francisco professor is urging hospitals not to serve meat from livestock raised on antibiot-ics because it could increase the inci-dence of drug-resistant bacterial infec-tions. In an opinion piece published in the American Journal of Public Health titled ‘Antibiotics Overuse in Animal Agriculture: A Call to Action for Healthcare Providers,’ UC San Francisco assistant clinical profes-sor of epidemiology and bio-statistics Michael Martin said that “hospitals have a moral responsibility to serve the community and patients” and should lead by example by not serving meat from livestock raised on antibiotics. The federal government has urged agri-cultural leaders to reduce the use of antibiotics in livestock but has not pro-hibited their use. “Because the actions

More Small Hospitals Sign Affiliation Deals with Larger ProvidersThree new agreements signed in October Three community hospitals in California this month signed affiliation agreements with larger health systems as part of an ongoing trend in which small hospitals are aligning with larger rivals. Tri-City Medical Center announced a pact with UC San Diego Health System that will allow the 330-bed hospital in Oceanside to remain independent while providing patients with access to specialty services available through UC San Diego. Under the affiliation deal, Tri-City patients with complex cases will be eligible for treatment at UC San Diego hospitals in La Jolla and San Diego that have advanced imaging, cardiac, oncological, and diagnostic services. “We considered a number of healthcare providers in San Diego County before making this decision,” said Tri-City CEO Tim Moran. “By affiliating with UC San Diego Health, the Tri-City Healthcare District greatly expands the depth and breadth of specialized medical care and surgical ser-vices available to our community.” Another San Diego County health system - Scripps Health - signed an affiliation agreement with Pioneers Memorial Healthcare District. The two-year agreement signed in early October will allow Scripps to provide training and consulting services for 107-bed Pioneers Memorial Hospital in Brawley, which is located 130 miles east of San Diego. “We’re trying to support the care in this community with the existing physicians who are already out there,” said Scripps CEO Chris Van Gorder. The agreement will allow Pioneers Memorial to transfer patients in need of spe-cialty care to Scripps, which operates five hospitals and 28 outpatient centers in San Diego County. Gardens Regional Hospital & Medical Center on October 12 signed a management services agreement with Paladin-Gardens Management LLC. Under the agreement, Paladin will oversee day-to-day operations at the 137-bed hospital in Hawaiian Gardens and “provide financial assistance to the hospital” to ensure that it maintains all hospital services and its emergency department. El Segundo-based Paladin also plans to hire a new CEO and CFO to head Gardens Regional Hospital. Several similar deals were signed earlier this year. In May, Stanford Health Care finalized a merger with ValleyCare Health System that made ValleyCare a subsidiary of Stanford Health. Under the agreement, Stanford will oversee the day-to-day operations of ValleyCare’s 242-bed hospital in Pleasanton along with its urgent care and outpatient facilities. And the California attorney general in May approved an affiliation agreement between Lodi Health and Adventist Health. The deal brought 191-bed Lodi Memorial Hospital and seven Lodi health clinics under the umbrella of Adventist Health, which agreed to spend $98 million on capital improvements for Lodi Health facilities.—DOUG DESJARDINS

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Nov. 12-13. Industry Collaboration Effort (ICE) Annual Conference. Hyatt Regency Hotel, San Francisco. A two-day event focused on healthcare indus-try trends of interest to physician groups, health plans, and healthcare organiza-tion executives. To register, please visit http://www.iceforhealth.org/eventde-tail2.asp?eid=68

Nov. 15-18. CAHF 65th Annual Convention & Expo. Renaissance Palm Springs and Palm Springs Convention Center. A gathering of healthcare pro-fessionals focused on new technologies and trends in long-term care. Sponsored by the California Association of Health Facilities. To register, please visit http://www.cahfconvention.com/

Dec. 2-4. CAPH/SNI Annual Conference. The Meritage Resort & Spa, Napa. A three-day gathering for safety-net providers in California. Sponsored by The California Association of Public Hospitals and the Safety Net Institute. To register, please visit http://caph.org/annualconference/

Dec. 4. CME Essentials. Children’s Hospital of Orange County, Orange. A workshop for healthcare profession-als interested in establishing or improv-ing a continuing medical education pro-gram. Sponsored by the Institute for Medical Quality. To register, please visit http://www.imq.org/Portals/23/CME%20Essentials%20Brochure-December%202015%20v3.pdf

of federal regulators have been insufficient, it is time for the healthcare sector to expand stewardship over these live-saving drugs beyond clinical practice,” Martin said. UCSF Medical Center has already phased out the use of meat at its facilities from livestock raised on antibiotics.

» The California Medical Association (CMA) House of Delegates approved a resolution restating its stance against tobacco use and called on the U.S. Chamber of Commerce to stop activities that promote tobacco use. The CMA resolution was approved one week after the CMA and other groups under the Save Lives California coalition introduced ballot initiative language to the state attorney gen-eral that would ask voters to approve a $2 per-pack tax on cigarettes in the state. “Smoking is the number one cause of preventable death in California,” said CMA president Steven Larson, MD. “The resolution passed this weekend, along with the recently filed initiative, will help people quit smoking and will fund research cures for cancer and other tobacco-related diseases.” The CMA and the Save Lives California coalition will need to gather more than 365,000 signatures of registered state vot-ers to qualify the initiative as a ballot measure for 2016.

» A new report from the Public Policy Institute of California (PPIC) showed that California’s prison population is getting smaller, a trend that may help the state regain control of prison healthcare from the federal government. Control of the state’s prison healthcare system was turned over to a federal receiver in 2006 fol-lowing a lawsuit that found prison healthcare was so bad that it constituted cruel and unusual punishment of inmates. In 2009, a federal judge ruled that prison over-crowding was the primary source of poor healthcare for inmates and ordered the state to begin reducing the inmate population in state prisons. According to a report in the San Bernardino County Sun, the prison population declined 17% in the first year from 160,800 to 133,400 due to a realignment that transferred inmates from state prisons to county prisons. “Hopefully, now that the population has come down, we’re able to provide the correct medical care,” said Brandon Martin, co-author of the PPIC report.

» Sutter Health is one of four finalists selected to potentially operate 80-bed Petaluma Valley Hospital when its current lease with St. Joseph Health System expires in 2017. According to a report in the Sacramento Business Journal, the four finalists are Sutter Health, Prime Healthcare Services, Strategic Global Management Inc., and the current lease-holder St. Joseph. Petaluma Valley is cur-rently owned by the Petaluma Health Care District. The four finalists will now be required to complete due diligence and submit a formal offer for the hospital by mid-December. The Petaluma Health Care District will then hold public forums to review the proposals before making its selection.

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Culture: The Key That Unlocks Your Performance Potential November 10 at 11:00am pst

Register today! go.cep.com/culture2015.html

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CULTURE EATS STRATEGY FOR BREAKFAST.

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

St. Joseph Heritage Healthcare is a statewide physician practice organization that works with physicians practicing in large multi-specialty groups, as well as small independent practices in over 30 different specialties. Recognized for excellence by the Integrated HealthCare Association and National Committee for Quality Assurance, SJHH provides members with extensive preventive care and education, as well as the benefits of an electronic medical records and online patient portal.

EXECUTIVE DIRECTOR, NETWORK SERVICES If you are a Leader that thrives on being close to the business, especially the phenomenal growth occurring on the frontlines of healthcare in physician practices, this position is for you.

In this role, you will be responsible for monitoring and managing physician relationships within our Southern California Affiliate Networks. The position will assist the Vice President, Affiliated Networks with network development, profitability and management in an effort to support the needs of the Provider Networks. In addition, the ED will act as a liaison of the St. Joseph Heritage Healthcare Affiliated Physicians pursuant to such Provider Relations/Operations or Business Development strategies sanctioned or sponsored by St. Joseph Hospital and/or St. Joseph Heritage Healthcare, and the implementation thereof. In this role the ED will be directly responsible for the St. Joseph Hospital (SJHAP). In addition to will have oversight and responsibility for the remaining Southern California affiliated networks at Mission Hospital (MHAP), St. Jude Hospital (SJAP), Hoag Hospital (HAP) and St. Mary’s (Premier Physicians) and their corresponding staff.

Not only will you find challenging work but also meaning and purpose in an organization that truly embodies its vision and values. You will be a part of the SJHH mission to bring “people together to provide compassionate care, promote health improvement and create healthy communities”. Not only are SJHH’s core values visibly posted but you will also be immersed in a culture that lives out these values as a reflection of yours and your team’s daily work. You will experience firsthand a commitment to care that extends to patients and employees alike and is the foundation of this enviable culture.

ESSENTIAL FUNCTIONS

Network Accountability: (40%) • Recommends strategy with the Vice President, Affiliated Network and

implements Provider contract terms, incentive plans and rates based on identifiable opportunities to enhance revenue, reduce costs, and limit financial risk.

• Monitors contract performance by analyzing rate structures, utilization trends and profitability. Maintains a consistent process and timeline for evaluating contracts based on recommendations of the providers or changing needs to of the environment. Keeps local Council, medical directors, and Vice President, Affiliated Network informed of and proactively resolves provider issues, which arise.

Provider Relations & Business Development (20%) • Maintains a high level of visibility in the provider network community.

Actively promotes positive relations with contract payors and other health care providers. Acts as liaison between the Heritage, Provider Network, Hospital, and Medical Group.

• Responsible for recruiting and adding new Physicians to the Network under the direction of the Medical Director and/or VP.

• Tracking, Trending and developing strategies to improve provider satisfaction, access and after hour study measures

Department Administration (40%) • Recruits, selects, trains, disciplines, discharges and develops staff

competent to achieve SJHMG goals and objectives.

• Supervises Department Staff. Conducts staff meetings and provides staff with standards of performance, informing them of job expectations. Oversee staff performance and provide appropriate and timely performance evaluations

• Oversees the formal response to all health plan appeals by gathering pertinent information for the Medical Directors review and monitors volume and number of overturns to insure effectuation of services in timely manner.

Minimum Position Qualifications: Education: Requires a Bachelor’s Degree in Business Administration, Healthcare Administration, or related field. Masters preferred.

Experience: Seven (7+) years Provider Relations experience within ambulatory, medical group, IPA setting required. Minimum of seven (7+) years leadership experience in a healthcare environment. Experience designing, managing and effectively leading organizational change initiatives.

Other: Valid California Driver’s License and automobile insurance for employee-owned vehicles.

Knowledge / Skills / Abilities: • Must be able to assume a high degree of independent functioning,

demonstrating prudent decision- making and flexibility.

• Must have a solid understanding of Per Diem, Capitated, Fee-for Service and Case Rate contracts.

• Must possess excellent verbal and written communication skills and an ability to work effectively with others.

• Must have fundamental understanding of the State and Federal health care guidelines for reimbursement.

• Ability to travel within St. Joseph Health locations

To apply, please send resume to Carissa.lopez@stjoe.org

St. Joseph Heritage Healthcare is now hiring for the following position:

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable.

Health Net, through its subsidiaries, provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as “Part D”), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net’s behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 4.9 million individuals, including Health Net’s own health plan members. Health Net’s subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.

For more information on Health Net, Inc., please visit the company’s website at www.healthnet.com.

REGIONAL NETWORK DIRECTOR Oakland, CALIFORNIA

Job Summary: The Regional Network Director develops provider network strategies; negotiates, implements and maintains provider networks that consists of multiple or complex provider contracts in the region. Manages the activities of regional provider staff responsible for servicing the network, consistent with company goals, policies and objectives. Directs and manages networks (market, state or national based) and works on corporate projects. Ensures that Health Net is in compliance with federal, state and regulatory requirementsEducation: Bachelor’s degree in Health Services, Health Care/Hospital Administration required, or related field or equivalent health care experience; Master’s degree preferred.

Experience: 5-7 years extensive provider network management/health care management experience, of which 4–6 years of progressive network contract negotiation experience. Strong project management experience plus previous supervisory/management experience required. Experience in a health care management environment, which provided exposure to provider contracting, servicing, benefits interpretation, and internal operations of provider relation’s function. Thorough knowledge of negotiation skills gained through experience required.

• We offer a competitive salary, attractive incentive plan and comprehensive benefits.

• Health Net, Inc. supports a drug-free environment and requires pre-employment background and drug screening.

• Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Veterans/Disability.

To view the complete job description and/or to apply please visit our website at

www.careersathealthnet.com and view requisition #10602

As the health plan of choice for 20 years in the Central Valley, we are committed to supporting not only the health of our members but the health of our community. We have been serving individuals enrolled in publicly-funded programs in the health of the Central Valley since 1996. As a not-for-profit Health Maintenance Organization (HMO), we have a contract with California Department of Health Care Services (DHCS) to manage healthcare for Medi-Cal beneficiaries. Our success is driven by our mission to continuously improve the health of the communities we serve.

VP of Provider NetworksThis position is responsible for ensuring that the ongoing pro-vider network development, contracting, relations, and opera-tions of HPSJ are aligned to consistently deliver strategic and tactical business objectives, consistent with applicable regula-tions. VP, Provider Networks is also responsible for HPSJ’s TPA business operations and relationships with San Joaquin County and Broker.

Candidates Required Qualifications:

• Bachelor’s Degree in Business, Public Administration or similar

• At least eight years progressively responsible leadership positions in healthcare and/or insurance settings, which includes oversight of network development, contracting, and provider services/operations; and

• At least five years supervisory experience.

• In-depth knowledge of the principles and practices of network development and contracting, including provider reimbursement methodologies.

• In-depth knowledge of the health care industry, its critical issues and major challenges.

• In-depth knowledge of health care delivery systems as they relate to assigned areas of responsibility.

• In-depth knowledge of operations best practices and met-rics, and ability to utilize them to obtain desired results.

• In-depth knowledge of regulatory guidelines as they relate to assigned areas of responsibility.

• Very strong negotiation skills, including a demonstrated ability to negotiate complex service levels and rates.

• Very strong collaboration skills, with demonstrated abil-ity to create and foster a collaborative work environment, maintain effective, high performance teams, and organize people and resources to solve problems and identify business opportunities.

For a complete job description please visit us at: https://hpsjcareers.silkroad.com/

Health Plan of San Joaquin is an equal opportunity employer; www.hpsj.com

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

Kern Health Systems is currently accepting applications for the following positions:

• Clinical Intake Coordinator Registered Nurse I

• Disease Management Case Manager Registered Nurse

• Medical Director

• Programmer IV

• UM Registered Nurse Facility Based

Compensation is based on experience, education and qualifications. For a complete position description on these exciting career oppor-tunities, please visit our career center at kernhealthsystems.com or

email resume to: recruitment@khs-net.com. E.O.E

HEALTHLEADERS INC. 10/26t/20151LA030971B

3.65 x 4.25” (4c process) CLIN CSI0000003

jme N/A

Cedars-Sinai is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace. EEO/AA/F/Veteran/Disabled

Exceptionally developed skills, a dedication to excellence and a desire to transcend the ordinary. This is the source of true art. It is also the foundation for the world-class healthcare provided at Cedars-Sinai. Our people bring an unmatched passion to their craft and it shows in everything they accomplish. If you want to be your best, you owe it to yourself to work with the best. You’ll have that opportunity when you work at Cedars-Sinai Medical Network.

Physician Network Development Manager Encino & Beverly Hills, CA

This position will take on a lead role in building Cedars-Sinai’s HMO provider network in strategic markets poised to accept HMO, PPO and Medicare patients. Involves partnering with the Director of Network Development to build a high quality, integrated delivery network while focusing on developing relationships with and recruitment of PCPs, specialists and ancillary providers. The successful candidate will have the expertise required to research/maintain market intelligence on the managed care provider landscape, analyze complex business problems and identify optimal solutions. Requires a BA/BS degree with 5+ years of healthcare industry experience, preferably within a managed care setting. MS degree in Public Health or Health Services Administration preferred.

In addition to professional development opportunities, Cedars-Sinai offers a competitive compensation and benefits package. For more information or to apply, visit us online at: https://www.cedars-sinaimedicalcenter.apply2jobs.com/ and reference Req #M10579.

cedars-sinai.edu/careers

Contract Specialist – Rancho Cordova, CA

Requires 3+ years of experience in analysis, negotiation and implementation of managed care and downstream provider contracts and provider relations activities. We offer 100% employer-paid medical coverage, comprehensive dental and vision plans, and a 403(b) retirement plan with company match.

Not-for-profit, EOE. © 2015 Dignity Health

Choose a career that gives back: careersatdignityhealth.com/Healthfax

Change jobs.Change lives.

All qualified candidates must submit an online application. Online applications and full

job descriptions can be found at: http://www.goldcoasthealthplan.org/about-us/careers.aspx

Gold Coast Health Plan is currently accepting applications for the

following positions:

√ Executive Assistant

√ Claims Transaction Manager

√ Care Management, RN

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

EXCEPTIONAL PEOPLE, EXTRAORDINARY CARE, EVERYTIMEAt MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. MemorialCare stands for excellence in Healthcare. Across our family of medical centers and physician groups, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

FEATURED OPPORTUNITIESExecutive Director Claims Administration #322301Bachelor’s degree or equivalent/relevant experience required, Master’s degree preferred. Minimum 12 years of successful history in operations in a managed care environment, a minimum of 7 years directly with IPA or medical group in a claims payment environment.

Director, Provider Networks/Relations #323082Bachelor’s degree required, 7-10 years of experience in Provider Relations, Customer Service, Credentialing or equivalent experience; Must have expertise in managed care provider portals and a minimum of 5 years management experience.

OPERATIONS• Manager, Accounting • Manager, System Contracting• Managed Care Analyst• Lead, Payroll

• Case Manager P/T & Per Diem• Manager, Coding Compliance• OP Ancillary/Physician Coder• And many more----------

INFORMATION SERVICES• Clinical Application Specialist (Radiant)• And many more----------

• Business Systems Specialist (Tapestry)

CLINICAL• RN Supervisor• RN Assistant Supervisor• LVN, Case Manager (Seaside Health)• FOA Supervisor

• Practice Manager• RN Team Lead• Complex Nurse Specialist• FOA Team Lead

Application Process: To learn more about these opportunities and more or to submit an application, please visit our website at http://www.memorialcare.org/careers

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

HEALTHCARE PARTNERS MEDICAL GROUP, a division of DaVita HealthCare Partners, Inc. (DVA: NYSE), is a top-rated Southern-California medical group and is widely recognized for its achievements in clinical excellence and patient satisfaction. Since 1992, HealthCare Partners has been committed to developing innovative models of healthcare delivery that improve patients’ quality of life while containing healthcare costs. HealthCare Partners manages and operates medical groups and affiliated physician networks in Arizona, California, Nevada, Florida, New Mexico and Colorado. (http://www.davitahealthcarepartners.com/)

We are committed to bringing the benefits of coordinated care to our patients and to taking a leading role in the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all. If you’re looking to make a difference with a large, financially stable, well-recognized medical group, DaVita HealthCare Partners may be the employer for you.

As part of our continued growth, we are currently seeking an outgoing Director, Regional IPA Operations to join our team in Torrance, CA.

DIRECTOR, REGIONAL IPA OPERATIONS Torrance, CA

Responsible for planning, directing, coordinating and supervising the functions and activities of the IPA primary care network(s) and specialty delivery networks at Healthcare Partners (HCP). Develops and monitors goals, implements and manages budgets, oversees enrollment growth and retention, patient satisfaction, provider network relations and education. Assists the Vice President, regional Operations in the overall administrative direction of the region. Requires Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college, and a minimum of 7 years management experience. Master’s degree in Health Care Administration, Business Administration or Nursing, 4 to 6 years management experience in health care (preferably in a medical group or IPA setting), and IPA network development experience preferred.

We offer a competitive salary and benefits program including Health, Dental, Vision, employer-matching 401(k), Continuing Education, Tuition Reimbursement, free Basic Life and AD&D insurance, company paid Long Term Disability, a generous Paid Time Off schedule, and more.

For immediate consideration please apply online at www.healthcarepartners.com or send to CV to

Carol Caputo, PHR, Recruitment Consultant at CCaputo@healthcarepartners.com

CHM is a management services organization (MSO) providing all of the services required to operate an Independent Physician Association (IPA). In addition to the owned IPAs, MSO services are delivered for a licensed Knox-Keene entity, CMS MSSP ACO, and client IPAs, with the aim of providing physicians and patients with additional choices for high-quality, affordable care.

VP, Clinical Services Requisition # 1505040814

Manager, Business Development & Marketing Requisition # 1505050088

IPA Manager Requisition # 1505050089

Resumes may be sent to Carla.Wilson@coasthealthcare.net. For full details and to apply, please visit tenethealth.com/careers and search by the req. number.

This position will be responsible for developing, implementing and managing strategies to ensure achievement of company growth.

This role provides services and support of internal IPA operations with regards to providers, member relations and contracting, including network and business development

The VP is responsible for reviewing activities, costs, operations and forecast data to monitor progress toward departmentally related company goals and objectives while managing operations of various business units, including Utilization Management, Inpatient Management, and Case Management

For more information, please visit our website at: http://www.scanhealthplan.com/careers/

CARE MANAGER – SOCIAL WORKER Req. #15-1952

COMMUNITY HEALTH WORKER Req. #15-1951

COMPLEX CARE MGR RN – BILINGUAL SPANISH Req. #15-1879

DATA ANALYST SR. – HEALTHCARE SERVICES Req. #15-1840

DATA ANALYST SR. – HEDIS & MEDICARE STAR Req. #15-1694

HEALTHCARE ANALYST SR. Req. #15-1919

NETWORK MANAGEMENT LEAD Req. #15-1890

NETWORK MANAGEMENT SPECIALIST Req. #15-1891

PART TIME NP (STOCKTON, CA) Req. #15-1963

PHARMACY ANALYST Req. #15-1739

PROJECT MANAGER Req. #15-1969

PROJECT MANAGER – HCI Req. #15-1863

PROJECT MANAGER – PHARMACY Req. #15-1907

SQL DATABASE ADMINISTRATOR Req. #14-1591

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

MEDICARE RISK ADJUSTMENT DIRECTORResponsible for leading the enterprise Risk Adjustment program and ensuring that risk exposures and opportunities are identified with the key objective of optimizing revenue integrity and accuracy. This posi-tion also has responsibility for retrospective and prospective strategies and the internal Risk Adjustment team, and works with the prospec-tive team to drive enhanced physician engagement and member inter-action. The Medicare Risk Adjustment Director will have accountability to the senior management leaders of HPSM.

Accountable for the operating result and ultimate outcome of Risk Adjustment program and provides strategic direction for a high functioning risk adjustment team responsible for all risk adjustment plan execution. Provide leadership and guidance for overall Risk Adjustment programs as well as identifying and application of best practices to ensure efficacy and accuracy of risk adjustment programs. Develop and regularly update risk adjustment policies and procedures. Facilitate relationships of the cross-functional and integrated process across the organization and with key segment leaders to develop pro-grams and streamline and leverage risk adjustment related activities including prospective services (member and provider engagement, and in-home/supplemental assessments) and retrospective activities. Provide reporting and analysis of revenue results to assist product development strategy and bid support. Model and monitor risk adjust-ed revenue by line of business and review cost and utilization trends to understand impact on revenue. Drive the preparation of analysis and reporting of ongoing revenue trends across multiple product lines and provide ongoing revenue variance reporting and mitigation planning. Develop strategic plans by determining goals, metrics, timeframes and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives. Oversee risk adjustment related activities and compliance, including but not limited to HCC programs, Risk Adjustment Data Validation (RADV), enroll-ment, and special status and encounter data to ensure achievement of accurate, timely, and expected outcomes. Oversee and manage external vendor relationships, including audits, for performance and compliance.

Education and Experience Equivalent to: Bachelor’s Degree in Business Administration, Finance, Health Care Management, or related field, required. Master’s Degree or above is preferred but not required. Five (5) years in a managed care setting with at least three (3) years in a risk adjustment leadership type role. Prior management experi-ence of at least two (2) years in a supervisory role, especially in leading teams, required.

CARE COORDINATION UNIT MANAGERManage and provide clinical oversight of the Care Coordination Unit. This includes staffing, supervision, and oversight of clinical and sup-port staff. Areas of responsibility include external, collaborative, and primary care coordination. Report to the Deputy Chief Medical Officer.

Education and Experience Equivalent to: Bachelor’s degree in nurs-ing, pharmacy, social work, or other healthcare related field; a Master’s degree is preferred. Three (3) years of management experience in a health care and/or managed care field. Experience with Medicare-SNP programs preferred.

Licensure and Certification: Valid California license as a Registered Nurse or Licensed Clinical Social Worker

COMMUNICATIONS AND MARKETING DIRECTORManage communications and marketing activities for HPSM programs and services. Coordinate development/production of materials to mem-bers and providers. Play key role in championing member and provider acquisition and retention. Position the HPSM brand and reputation to internal and external stakeholders. Will report to the Director for Strategy and Business Support Services.

Education and Experience Equivalent to: Bachelor’s degree in health care, public affairs/policy, business, marketing, or communications. Five plus years healthcare marketing experience including market positioning and messaging, product launch and integration, customer based market-ing and regulatory requirements preferably in the managed care sector, but not required. In depth experience leading: content strategy, public relations, production processes, and communication programs.

QUALITY IMPROVEMENT SUPERVISORResponsible for development and implementation of Quality Programs including HEDIS and Pay for Performance Programs (P4P). Assist in implementation of quality programs consistent with Quality Department goals. Oversee activities, resources and processes to achieve improvement in HEDIS and P4P measures, including assign-ment of nurses, adherence to plan timelines, and vendor oversight for timeliness and quality. Will report to Quality Improvement Manager.

Education and Experience Equivalent to: Three plus years in health care/managed care with responsibility for researching, analyzing, plan-ning, evaluating or coordinating projects. Bachelor’s degree in health care planning or related field. Master’s degree in public health, public policy or public administration, training in analysis, reporting and orga-nizational management preferred. Advanced working knowledge of HEDIS specifications, performance incentive programs and principles of quality improvement.

BENEFITS INFORMATION: Excellent benefits package offered including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for com-pensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

APPLICATION PROCESS: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 701 Gateway Blvd., Suite 400, South San Francisco, CA 94080. or via Email: careers@hpsm.org or via Fax: (650) 616-8039 File by: Continuous until filled. EOE

Please visit our Careers page at http://www.hpsm.org/abouthpsm/employment-opportunities.aspx

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F E A T U R E D C A R E E R O P P O R T U N I T I E S

California Health & Wellness is the first new Medi-Cal Managed Care Plan in California in nearly a decade. It is the California division of Centene Corporation (Centene) that has established itself as a national leader in the healthcare services field. Today, through a comprehensive portfolio of innovative solutions, we remain deeply committed to delivering results for our stakeholders: state governments, members, providers, uninsured individuals and families, and other healthcare and commercial organizations.

DIRECTOR, MEDICAL MANAGEMENT

Direct medical management program including utilization management, case management, quality improvement and credentialing in accordance with the mission, philosophy, and objectives of plan and in conjunction with Corporate goals and objectives.

Responsibilities: Develop department objectives and organize activities to achieve objectives. Evaluate and implement changes to medical service functions and performance in relation to company mission, philosophy objectives and policies. Manage budget and forecast for strategic planning and key initiatives. Coordinate with operating departments on research and implementation of best practices. Responsible for the statistical analysis of utilization data on programs. Participate in NCQA, State, and/or other accreditations of the Plan. Organize and present new concepts, programs and tools to staff and other plan departments. Develop communication plans with external providers such as hospitals and State agencies as required to facilitate plan goals and objectives. Coordinate with Medical Director to educate and communicate expectations with providers.

Education/Experience: Bachelor’s degree in Nursing, related field, or equivalent experience. 7+ years of nursing, quality improvement, and management experience in a healthcare environment, preferable managed care. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.

License/Certification: RN license.

Please submit your resume to BGLICK@CENTENE.COM

HEALTHLEADERS INC. 10/26/20152LA030974B

3.65 x 8.65” (4c process) CLIN CSI0000003

rv/jcs N/A

Cedars-Sinai is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.

EEO/AA/F/Veteran/Disabled

At Cedars-Sinai Health Associates (CSHA), an IPA within the Cedars-Sinai Medical Network, our medical professionals bring everything they have in order to provide the highest caliber of care to our patients. It’s because of their compassion, their expertise, and their dedication that Cedars-Sinai Medical Network is consistently recognized for its quality and service. We’re currently seeking a talented Medical Director who shares our same outlook to join the CSHA team.

As an invaluable part of the Cedars-Sinai Medical Network, our CSHA Medical Director is responsible for providing senior leadership to a large network of individual physicians with independent offices throughout Los Angeles. These physicians have come together to form an independent physician association (IPA) to serve the community’s managed care medical needs. This position works collaboratively with the CSHA Board of Directors and administrative leadership of Quality, Clinical Efficiency, Care Transitions and Medical Group Operations to achieve mutual goals for the organization.

Requires current CA medical license and Board certification in one of the following specialties: Internal Medicine (preferable), Family Practice (preferable), Pediatrics, Internal Medicine Sub-specialty.

Learn more and apply by visiting www.cedars-sinaimedicalcenter.apply2jobs.com and reference Req #M10378.

cedars-sinai.edu/careers

Cedars-Sinai Health Associates is

SEEKING A MEDICAL DIRECTORto join its team in

Beverly Hills, California