top stories state legislators and governor reach accord on...
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June 22, 2015 | VOLUME 22 | NUMBER 25
T O P S T O R I E S
State Legislators and Governor Reach Accord on $115 Billion BudgetAgreement includes additional spending for Medi-Cal
California legislators and Gov. Jerry Brown reached an agreement on a $115.5 bil-lion state budget that includes $40 million to provide Medi-Cal coverage for children of undocumented immigrants.
“This is a sound and well thought-out budget,” said Brown. “Yet, the work never ends and, in the coming months, we’ll have to manage our resources with the utmost prudence and find more adequate funding for our roads and healthcare programs.”
One of the largest increases is an additional $226.7 million for the state’s In-Home Supportive Services (IHSS) program, which was a frequent target for budget cuts during the recession. The funding will restore a previously approved 7% reduction in service hours for workers in the IHSS program, which assists elderly and disabled people in their homes and helps them stay out of nursing homes.
The budget also includes $40 million to fund healthcare coverage for chil-dren who are not in the country legally, an allocation that assumes Senate Bill 4 authored by Ricardo Lara (D-Bell Gardens) will be approved by the state legisla-ture. SB 4 would provide Medi-Cal coverage for all children regardless of their immi-gration status beginning in May 2016. Senate president pro tempore Kevin De Leon (D-Los Angeles) said that “with this budget, we’re saying that immigrants matter, irrespective of who you are or where you’re from.” The program would provide cover-age for approximately 170,000 children.
The budget also includes several healthcare spending measures that Brown approved in his May Revise budget. They include $228 million for high-cost prescrip-tion drugs to treat problems like Hepatitis C and HIV/AIDS with the money ear-marked for several state agencies including the Department of State Hospitals and the state Department of Rehabilitation and Corrections. Brown also approved a $48 million spending increase for the state’s Medi-Cal program to cover additional costs generated by the rapid growth of the program.
Brown scheduled a special legislative session for June 19 to discuss several healthcare-related measures, including calls for increasing Medi-Cal reimbursement rates for providers and making the 7% increase in IHSS funding permanent.
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T O P S T O R I E S CONTINUED FROM PAGE 1
State Legislators cont. » California’s teen birth rate con-
tinued to decline in 2013. According to a report from the California Department of Public Health (CDPH), the rate of births among teenag-ers aged 15 to 19 was 23.2 births per 1,000 females, down from 26.2 births per 1,000 in 2012 and 46.7 births per 1,000 in 2000. Marin County had the lowest teen birth rate in the state at 8.1 births per 1,000 and Kern County had highest rate at 49.1 births per 1,000. “California’s continued suc-cess in reducing adolescent births is an excellent example of public health at work,” said CDPH director Karen Smith , MD . “By providing adoles-cents with the knowledge, tools, and resources to make healthy choices, we can have a positive effect on their options for a successful future.” State-sponsored programs designed to lower teen birth rates include the Adolescent Family Life Program and the Personal Responsibility Education Program.
» A l a m e d a H e a l t h S y s t e m announced the launch of a mobile MRI unit at San Leandro Hospital to provide patients with outpatient and inpatient screening services. “The mobile MRI unit allows us to provide an important medical imaging service that is faster and more convenient for our patients,” said Steven Rosenthal, MD, associate chief medical officer for 93-bed San Leandro Hospital. “This advanced medical technology helps us provide critical testing for our patients and provides their physicians with the ability to develop treatment plans right
Anthony Wright, executive director of Health Access California, said he hopes that legislators will resurrect a proposal to restore several Medi-Cal benefits that were eliminated in 2009 during recession-era cuts that include podiatry, optical services, and speech therapy. “We hope the special legislative session on Medi-Cal funding will provide the opportunity to revisit restoration of Medi-Cal benefits and rates and improve access in general,” said Wright. Several healthcare organizations, including the California Hospital Association (CHA) and the California Medical Association, have been pushing for Brown to reverse 10% cuts to Medi-Cal and raise Medi-Cal provider rates, which are among the lowest in the country. “Hospitals and other providers are paid by Medi-Cal at rates substantially below Medicare, placing healthcare providers and their patients in a precarious position,” said CHA president C. Duane Dauner. Brown has resisted efforts in the past to increase Medi-Cal spending, particularly on reimbursement rates that were reduced by 10% in 2011 with the approval of Assembly Bill 97. Scott Graves, director of research for the California Budget & Policy Center, said the fact the governor and legislators were able to reach an agreement on some of the major healthcare funding issues makes it less likely he’ll veto health-care spending items before the final budget is approved by July 1. “There’s nothing that prevents the governor from making line-item vetoes before the final budget is approved,” said Graves. “But the fact that he reached an agreement with legislators and made it public is a pretty good indication that he doesn’t plan any vetoes, at least on any high-profile items. —DOUG DESJARDINS
Two San Francisco Hospitals to Ban Sugar-Sweetened BeveragesProducts will not be sold or served to patients and visitors
Two hospitals in San Francisco are phasing out sugary beverages as part of an effort to promote healthier diets among patients, workers, and visitors.
San Francisco General Hospital and Trauma Center started its sweetened-beverages ban on June 12. The new policy excludes sugar-sweetened beverages from patient meals and bans the sale of sugary beverages at gift shops, cafeterias, and in vending machines.
“Our patients disproportionately suffer from chronic diseases and we know that consuming sugar-sweetened beverages does not help,” said San Francisco General CEO Sue Currin in a statement. “With the healthy beverage initiative, we are making it easier for people on campus to make better choices about what to drink.”
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away.” The MRI unit will be available at San Leandro Hospital on Tuesdays and Thursdays and at Alameda Hospital, which is also operated by Alameda Health System, on Mondays, Wednesdays, and Fridays.
» According to a report in the Sacramento Business Journal, federal data shows that Florida has enrolled more people under private plans through federal healthcare reform than California, with 1.42 million people enrolled for coverage as of March 31 compared to 1.36 million in California. Texas had the third-highest enroll-ment total at 966,400. Experts say Florida’s enrollment figure is higher because it has not enacted Medicaid expansion. Covered California esti-mates that approximately 85,000 peo-ple who purchased coverage through Covered California in 2014 dropped coverage after they became eligible for Medicaid. “It is apples and oranges,” said Anthony Wright, executive direc-tor of Health Access California. “A lot people were eligible for subsidies in the Florida exchange because the state didn’t expand Medicaid.”
» Marin General Hospital has earned a Get with the Guidelines-Stroke Gold Plus Quality Achievement Award from the American Heart Association . Hospitals participating in the voluntary program must achieve at least 85% compliance with achievement indicators for two or more consecutive 12-month periods and achieve at least 75% com-pliance with five of eight stroke quality
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A similar policy is due to launch at UC San Francisco Medical Center on July 1 and will be phased in over the next three months. “The science behind the impact of excessive sugar on chronic disease, particularly in the form of sweetened beverages, is already strong and growing,” said UCSF chancellor Sam Hawgood in a statement. “As a health sciences university and leading medical center, we see it as our responsi-bility to do our part to help reduce this impact on our own community.”
Laura Schmidt, a UCSF professor at the Philip R. Lee Institute for Health Policy Studies, said that the “average American consumes nearly three times the recommended amount of added sugar each day” and that “the most common single source is sugar-sweetened beverages.” In a press release, UCSF said the program will “roll out across all other campus sites throughout the summer, culminating at the Parnassus campus site in October.”
The hospital initiatives coincide with a new law approved by San Francisco city officials in June that will require all advertisements for sugar-sweetened beverages in the city to come with a warning that states “drinking beverages with added sugar contributes to obesity, diabetes, and tooth decay …”
CalBev, a division of the American Beverage Association, did not comment on the policies adopted by San Francisco General and UC San Francisco but said the city’s warning label legislation is “misguided” and overstates the role of sugary bever-ages in public health problems such as diabetes.
“We’ve very disappointed that supervisors are taking the expedient route and scapegoating sugar-sweetened beverages,” said Roger Salazar, a spokesman for CalBev. “The measures don’t do anything to improve public health.”
CalBev has opposed several ballot initiatives and legislative proposals in California calling for warning labels and new taxes on sugary beverages. Earlier this year, it came out against Senate Bill 203, which would have required beverage manufacturers in the state to place warning labels on some products about the dan-gers of consuming excess sugar. CalBev described the bill, which failed to advance out of the Senate Health Committee in May, as a “misguided policy.”
The California Hospital Association (CHA) said it doesn’t have a program that actively encourages hospitals to ban sugar-sweetened beverages but that it supports efforts to promote healthy lifestyles. “A lot of hospitals are launching programs to pro-mote healthy living, whether it’s promoting healthier diets or banning cigarette smoking,” said CHA vice president of external affairs Jan Emerson-Shea. —DOUG DESJARDINS
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measures. “This award demonstrates the hospital’s commitment to ensure that stroke patients receive care based on nationally respected clinical guidelines based on the latest scien-tific evidence,” said neurologist John Panagotacos, MD, medical director for Marin General’s stroke program. Marin General, a 235-bed acute care hospi-tal, said that it’s also been certified as a Primary Stroke Center by the Joint Commission.
» Ridgecrest Regional Hospital was partially evacuated on June 11 due to a fire on the second floor of one of the hospital’s buildings. According to a report in the Bakersfield Californian, the fire was caused by a compressor that caught fire in a closet. Firefighters said that two adults suffered minor smoke inhalation in the fire and that the blaze caused an estimated $15,000 in damage at the 55-bed hospital locat-ed east of Bakersfield.
» KPC Health is renaming four of its hospitals located in Orange County as part of a strategy to strengthen ties with local communities. According to a report in the Orange County Register, the name of Western Medical Center Santa Ana will be changed to Orange County Global Medical Center ; Western Medical Center Anaheim will be renamed Anaheim Global Medical Center; Chapman Medical Center will be renamed Chapman Global Medical Center, and Coastal Communities Hospital in Santa Ana will be renamed South Coast Global
Dual-Eligible Managed Care PlanExpanding to Orange County Orange to join six other counties in coordinated care plan
Orange County will launch its coordinated care initiative for dual-eligible patients in July to join a pilot program underway in six other counties. CalOptima will launch Cal MediConnect in Orange County when it begins voluntary enrollment on July 1 for OneCare Connect, its version of the man-aged care program. CalOptima said it expects to enroll up to 29,000 dual-eligible Medicare-Medicaid patients in Orange County into OneCare Connect. “This new program offers eligible seniors and people with disabilities coor-dinated, personalized care to address their complex needs,” said CalOptima CEO Michael Schrader. “OneCare Connect members have access to more services and more support, which will have a positive impact on their health and help them maintain their independence.” The Cal MediConnect pilot project may eventually include more than 456,000 dual-eligible patients in Orange, Los Angeles, San Bernardino, Riverside, San Diego, Santa Clara, and San Mateo counties. The program was scheduled to launch in April 2014 but several counties delayed their launches for several months to address plan readiness and enrollment schedules. The goal of the program is to better coordinate care for dual-eligible patients who typically have multiple chronic conditions and to generate cost sav-ings by better managing their care. A report from the Congressional Budget Office estimates that dual-eligible patients accounted for just 13% of all Medicare and Medicaid patients in 2009 but generated 34% of total costs. To date, Cal MediConnect has enrolled 122,787 dual-eligible patients into the program. Los Angeles County leads enrollment with 54,773 members followed by San Diego County with 18,745. They are followed by Riverside County (14,768), San Bernardino County (14,680), San Mateo County (10,087), and Santa Clara County (9,734). The state Department of Health Care Services (DHCS) projects total enrollment will hit 132,981 by the end of July. The DHCS also plans to transition members of the state’s Multipurpose Senior Services Program (MSSP) into managed care plans but said that transi-tion will be delayed. Senior healthcare advocates asked the DHCS to delay the program to address continuity of care issues for MSSP members. “Similar to delays experienced when implementing the Coordinated Care Initiative [Cal Mediconnect], MSSP integration into managed care also expe-rienced delays and operational changes, which DHCS and the Department of Aging focused on mitigating and resolving,” said DHCS spokesman Tony Cava. “Ultimately, these challenges slowed the essential preparation needed to begin MSSP transition.” —DOUG DESJARDINS
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July 19-22. CAHF and QCHF Institute Summer Conference. Loews Omni La Costa, Carlsbad. An educational conference for healthcare profes-sionals sponsored by the California Association of Health Facilities and the Quality Care Health Foundation Institute. To register, please visit http://www.cahf.org/MeetingsEvents.aspx
July 23-25. American Hospital Association Health Forum and Leadership Summit. San Francisco Marriott Marquis. An educational confer-ence for healthcare executives with an emphasis on new trends in patient care. To register, please visit http://www.health-forum-edu.com/summit/registration.dhtml
July 31-Aug. 2. Primary Care Summer Conference. Loews Coronado Bay Resort. An educational conference for primary care physicians focused on programs to improve patient outcomes in a broad range of therapeutic areas. Sponsored by Scripps Health. To register, please visit http://www.scripps.org/events/primary-care-summer-conference-july-31-2015
Aug. 20-21. USC Sixth Annual Pain Management Symposium. University of Southern California, Los Angeles. A two-day seminar focused on the latest advanc-es in pain management and new trends in patient-centered care for managing pain. To register, please visit http://www.keck.usc.edu/events/6th-annual-pain-manage-ment-symposium-from-evidence-to-clini-cal-practice/
Medical Center. “We now have a different goal with our hospitals,” said Suzanne Richards, chief executive of KPC Health. “We want to become very large in the com-munity again. We want to re-establish ourselves as community assets again.” KPC Health, which was formerly known as Integrated Healthcare Holdings Inc. (IHHI), purchased the hospitals from Tenet Healthcare in 2005 and owns three other hospi-tals in California.
» The California Department of Public Health (CDPH) is advising California resi-dents who develop a fever or respiratory illness within two weeks after visiting the Middle East or any healthcare facility in South Korea to be aware they may have contracted Middle East Respiratory Syndrome (MERS). The CDPH said anyone who develops these systems after visiting these areas should call ahead to their healthcare provider before coming in for an appointment so that extra precautions can be taken. “The risk of MERS in California remains very low and is related to recent travel to affected regions overseas,” said CDPH director Karen Smith, MD. “The emergence of MERS in South Korea should remind patients to tell healthcare providers about any travel, while medical professionals should ask their patients about recent travel.” To date, 63 people with possible MERS cases have been report-ed to the CDPH but all have tested negative.
» A civil suit filed against San Joaquin Valley Rehabilitation Hospital claiming that a former patient was abused has been dismissed. According to a report in The Business Journal, a Fresno County Superior Court judge dismissed the case cit-ing insufficient evidence. The complaint filed in 2014 claimed that an 85-year-old patient at San Joaquin Valley was neglected and assaulted during her stay there. San Joaquin Valley officials said in a press release that investigations into the alle-gations conducted by California Department of Public Health and the Fresno Police department did not produce evidence of abuse or neglect. In a statement, San Joaquin Valley Rehabilitation Hospital said that it was “pleased with the outcome of this case.” Officials from the law firm that filed the civil lawsuit could not be reached for comment.
» Covered California awarded new contracts to marketing and public relations firms that will promote the health insurance exchange. The Los Angeles-based firm Campbell Ewald was awarded a three-year marketing contract worth $50 million per year retroactive to June 1. Ogilvy Public Relations was awarded a three-year contract worth $2 million per year. “Covered California will be building on its suc-cesses of the first two years and continuing the effort to make sure everyone who needs health insurance is aware of the low-cost options available to them,” said Covered California executive director Peter Lee. Covered California said it received bids from eight firms for the marketing contract and four bids for the public rela-tions contract.
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March 31, 2014 | VOLUME 30 | NUMBER 12
T O P S T O R I E S
Number of Physicians in State has
Increased 39% Since 1993
Many areas still have shortage of physicians
A new study from the California HealthCare Foundation (CHCF) shows the
number of physicians in California has increased 39% over the last two decades but
that not all regions of the state are benefiting from the increase.
The study titled California Physicians: Surplus or Scarcity? estimates that
the number of physicians in the state increased 39% from 66,151 in 1993 to 91,775
in 2011, a percentage that’s nearly double the state’s 20% increase in population
during that period. But despite that increase, the report shows many regions of the
state still have a shortage of physicians.
The federal government recommends that communities have between 60 and
80 primary care physicians for every 100,000 residents to ensure adequate access
to care and between 85 and 100 medical specialists for every 100,000 residents.
In 2011, California met that requirement statewide with 64 primary care physi-
cians for every 100,000 residents and exceeded it with 130 specialists for every
100,000 residents.
But the study showed sharp disparities in physician supply by region. The San
Francisco Bay Area had 86 primary care physicians and 175 specialists for every
100,000 residents in 2011, well above the state average. On the flip side, the San
Joaquin Valley had only 48 primary care physicians and 80 specialists for every
100,000 residents. The Inland Empire, a region in Southern California made up of
Riverside and San Bernardino counties, had only 43 primary care physicians and
77 specialists for every 100,000 residents.
“There are efforts underway to get more physicians to practice in those
areas,” said Robbin Gaines, a senior program officer for the CHCF. “But it’s going
to take a while.” One program provides doctors who recently graduated from medi-
cal school with up to $105,000 in student loan payments in return for practicing in
an underserved area of California for three years.
One trend in California’s favor is the percentage of medical school graduates
who choose to remain in California after they graduate. The study showed that
62% of students who attended medical school in California remained in the state
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Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. We serve over 1,000,000 members in Riverside and San Bernardino counties in Medi-Cal,Cal MediConnect Plan, Healthy Kids and a Medicare Special Needs Plan. Our success is attributable to our Team who share the IEHP mission to organize the delivery of quality healthcare services to our members. Join our dedicated Team!
ASSISTANT COUNSELBachelor’s Degree in a related field and Juris Doctorate from a top tier law school. Must have an active license to practice law in California. A minimum of 3-5 years combined experience in a law firm, corporate, or government setting. Federal (CMS) and State agency (DHCS, DMHC) experience highly preferred. Health care law, health plan, hospital operations experience is a plus. Must have strong understanding of regulatory requirements for a public agency in the delivery of health care services.
Strong knowledge of the managed care industry and policy issues impacting managed care. Must possess excellent communication, presentation, interpersonal and research skills. Ability to analyze case law and develop recommendations. Ability to develop and leverage one or more of the following areas of legal specialization: Medicare/Medicaid regulations, health plan operations, and health care transactions. Must have ability to exercise a high degree of initiative to handle and prioritize multiple matters simultaneously and effectively in a high-volume environment.
CREDENTIALING MANAGERBachelor’s degree preferred. Education requirement may be waived if candidate has extensive supervisory experience in a healthcare credentialing and recredentialing environment. Minimum of three (3) years prior supervisory experience, five (5) years experience with a managed care organization working directly with the credentialing of physicians, thorough knowledge of NCQA credentialing and recredentialing standards. Prior audit experience required. Possession of a valid California Drivers license and valid auto insurance for travel within Southern California.
Proficient in Microsoft applications (Word, Excel and extensive knowledge in Access). Excellent written and verbal communication and interpersonal skills, ability to establish and maintain effective working relationships with others. Ability to supervise and train team members, strong organizational skills, detailed oriented, sound decision making skills required. Ability to speak publicly.
FINANCIAL ANALYST Bachelor’s degree required. Minimum three (3) years of Finance experience. Experience and knowledge of complicated budgets preparation and budget to actual analysis in Excel. Experience in Managed Care preferred and statutory reporting a plus.
Strong knowledge and demonstrative proficiency utilizing Microsoft Applications (Word, Excel, Access & PowerPoint). Strong understanding of accounting and financial principles and methodologies and attention to detail. Experience with Oracle or Hyperion a plus. Principles and practices of health care industry and strategies, health care systems, and budget modeling and forecasting.
PROVIDER PRACTICE MANAGER Bachelor’s degree required. Managed care experience required. Minimum of three (3) years of experience in provider practice management in healthcare industry. Familiarity with Medi-Cal and Medicare preferred. Ability to develop, analyze, apply applicable organizational policies and
programs effectively. Managed Care principles and practices of project management. Proficient in Microsoft Office products and Visio. Strong work ethics, written, interpersonal and communication skills; Ability to work under tight deadlines and manages projects independently; resourcefulness and independent in solving problems; superior professionalism and self-direction; strong attention to detail.
CLAIMS ANALYSTBachelor’s degree in Business Administration, Public Health, Public Policy or a related field required. Masters Degree preferred. For non-degreed candidates, two (2) years of applicable experience may be substituted for each year of college required. Minimum of five (5) years experience in a health plan setting and having a project management role in the operational areas of claim processing.
Thorough knowledge of Medicare managed care and Medicaid managed care preferred. Must possess strong knowledge of claims processing, regulatory requirements, data analysis, project management and across-organization coordination. Must have high degree of patience, attention to detail, excellent writing skills, interpersonal, communication, project management and organizational skills required. Strong computer skills in Microsoft Word, Excel, and Visio. Knowledge of Microsoft Access preferred.
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CLAIMS QUALITY AUDITING & TRAINING MANAGERBachelor’s degree preferred. Education requirement may be waived if candidate has extensive supervisory and operational experience in a medical claims payer environment. Five (5) years of medical claim operations experience with at least three (3) years in a related supervisory capacity. Compliance audit experience preferred. Extensive experience writing policies & procedures and training documentation. Highly organized with the ability to balance multiple projects and meet deadlines. Strong presentation skills. Ability to transform concepts into business operations. Experience in a Lean strategy environment highly desired.
Solid understanding of Medi-Cal and Medicare rules and regulations governing claims adjudication practices and procedures preferred. Demonstrated business training principles and techniques. Analytical skills with emphasis on time management, quality statistics, and problem solving. Strong writing, organizational, project management, presentation and communication skills required. Must have a high degree of patience, excellent interpersonal/communication skills.
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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
Ventura County, CaliforniaClinicas is a multi-specialty community health center organization located in Ventura County, California operating 13 health centers with an extensive specialty care network. Clinicas is searching for experienced individuals for the following positions:
• Director of Analytics and Business Intelligence
• Operations Manager
• Health Center Managers
• Compliance Coordinator
• Compliance Data Analyst
• Mental Health Therapists
Clinicas offers rewarding career opportunities with highly competitive salaries and excellent benefit packages.
To Apply: email resume to: [email protected]
To learn more about Clinicas del Camino Real, Inc., visit us at www.clinicas.org
Surgery Care Affiliates is currently hiring for a Director, Managed Care to work remotely for our Southern California Facilities.
DIRECTOR, MANAGED CAREThe position will enable SCA to achieve earnings growth by partnering with operations leaders to set and execute a strategy that combines payer contracting efforts with case mix, targeted volume growth initiatives, and strategic acquisitions.
Requirements:
• Travel to payor meetings, company meetings, center visits, etc. (30%)
• Extensive knowledge of payor contracting and payment systems
• Understanding of the basic operation of an ASC
• Understanding of ASC profit and loss statement
• Ability to heavily leverage data but also translate into understandable action plans for Field Operations
Education, Vocational Training and Experience:
• College Degree
• Healthcare and ASC operations experience a plus
• 5+ years payor contracting/reimbursement experience
If interested, please email your resume to Loden Arkema: [email protected]
Gold Coast Health Plan is currently accepting applications for the following positions:
√ Director of Risk Management
√ Health Education Program Supervisor
√ Utilization Review, RN
√ Senior Decision Support Analyst
√ Executive Assistant
√ Disease Management, RN
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
Do Work That MattersWe are Sutter Physician Services – an industry leader in providing patient access, revenue cycle, and accountable care solutions to health care provider and payer organizations. We take pride in our mission and believe in cultivating an environment that supports and values our greatest asset: talent. If you’re ready to add your abilities to our broad network of care, come realize your professional potential with Sutter Physician Services.
Sr. Director, Revenue Cycle Solutions Sacramento, CA
We are seeking a dynamic leader who will balance daily operations and positive client engagement while creating a vision for elevating our revenue cycle operations to the next level. This position will focus on Sutter-affiliated business and will lead large teams to execution of business plans to ensure optimal revenue cycle performance. A Bachelor’s degree and 10-15 years’ experience in a leadership role in the area of patient accounting for a large, multi-specialty medical group or hospital required.
For more information and to apply, please visit www.sutterphysicianservices.org/careers and search for job number 1511501.
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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, ContractingCoordinate, negotiate and handle activities of provider contracting, network development and/or provider relations functions. Aid in formulating and administering organizational policies, procedures. Negotiate large hospital, physician groups and ancillary service agreements in accordance with Corporate, health plan and government regulations and guidelines.Responsibilities: Oversee provider contracting activities to ensure efficiency and maintain compliance with Company policies and standards, government laws, regulations. Negotiate contracts with hospitals, physician groups and ancillary service agreements. Develop and implement network development plan for assigned region and set of providers. Identify and initiate contact with potential providers in support of the strategic goals and objectives. Effectively integrate new programs, strategies to reach per member per month targets. Provide oversight to provider set up and contract configuration in computer system to ensure accurate claims adjudication. Perform basic financial analyses to identify medical cost improvement opportunities, develop strategies to reach financial goals, and execute contracting strategies to meet goals, objectives. Evaluate and monitor providers’ performance standards and financial performance of contracts. Position to be based out of San Diego, Sacramento, Orange County, or Los Angeles. There will be some weekly travel within California.Education/Experience: Bachelor’s degree in Business Administration, Health Care Administration, related field or equivalent experience. 5+ years related experience negotiating hospital, large physician groups and ancillary service agreements and external customer service for providers. Experience in marketing/sales, medical economics in managed care or insurance environment. Previous management experience including responsibilities for hiring, training, assigning work, managing performance of staff. Experience in provider network management, Medicaid/ Medicare contracting, claims processing preferred.License/Certification: Valid driver’s license.Please submit your resume to [email protected]
Compliance SpecialistEnsure compliance with contractual requirements and federal and state government reporting and regulations. Maintain government relations for compliance activities.Responsibilities: Ensure compliance with contract provisions with various agencies and applicable State and Federal laws. Serve as compliance resource for day–to-day processes. Analyze and determine the best course of action for each inquiry/problem. Act as primary contact for initiating and coordinating compliance projects. Develop and update plan policies and procedures to ensure compliance with federal and state requirements. Conduct periodic assessments and audits to ensure compliance with contractual and regulatory requirements and timeliness of submission. Oversee the day-to-day health plan policies and procedures to ensure federal and state regulatory compliance.Education/Experience: Bachelor’s degree in related field or equivalent experience. 5+ years of compliance or regulatory experience. Advanced experience with Microsoft Office applications. Knowledge of business operations related to managed care preferred.Please submit your resume to [email protected]
Data Analyst IIIResponsible for analytic data needs of the business unit. Handle complex data projects and acts as lead for other Data Analysts.Responsibilities: Provide advanced analytical support for business
operations in claims, provider data, member data, clinical data, HEDIS, pharmacy, external reporting. Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources. Review data to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management. Develop reports and deliverables for management. Model data using MS Excel, Access, SQL, and/ or other data ware house analytical tools. Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analysis. Assist with training and mentoring other Data Analysts.Education/Experience: Bachelor’s degree in related field or equivalent experience. 4+ years of statistical analysis or data analysis. Advanced knowledge of Enterprise Reporting and Analysis tools, SQL, and Microsoft Office applications, including Excel and Access. Experience managing projects or heavy involvement in project implementation. Healthcare experience preferred.Please submit your resume to [email protected]
Health EducatorAssess and approve written health education materials designed to assist health plan members to modify personal health behaviors, achieve and maintain healthy lifestyles, and promote positive health outcomes, including updates on current health conditions, self-care, and management of health conditions.Responsibilities: Develop and maintain member health education materials. Review member health education materials for readability and suitability, including maintaining a checklist for auditing. Ensure proposed materials are appropriate for target audiences through research, field testing. Develop and provide seminars, educational programs within scope of practice. Provide input on changes to product descriptions and program practices related to health, wellness coaching. Assist coordination of annual events (health fairs, wellness events). Provide initial and ongoing health coaching to members. Provide participants with referrals to vendor partners when appropriate. Maintain accurate and timely documentation in member management software of all face-to-face, telephonic and written communications with participants.Education/Experience: Master’s degree in Public Health or Community Health with emphasis/specialization in health education/promotion or MCHES (Master Certified Health Education Specialist). 2+ years of health education experience.License/Certification: Current state RN license preferred.Please submit your resume to [email protected]
Medical Review NursePerform retrospective review of large hospital and physician claims for admission appropriateness, coding, length of stay, and pricing. Review retrospective medical necessity appeals against medical review criteria to make benefit determinations.Responsibilities: Perform retrospective high dollar claims for benefit, pricing-determination. Collect hospital medical records as appropriate and work with related hospital staff. Work with Finance Department to determine appropriateness of pricing. Maintain appropriate records, files, documentation, etc.Education/Experience: Bachelor’s degree in Nursing or related field. Licensed or Registered Nurse. Advanced degree and/ or certification preferred. 2+ years in acute care nursing and utilization review. Knowledge of managed care programs and practices required.License/Certification: Licensed or Registered NursePlease submit your resume to [email protected]
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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 inno-vative models of healthcare delivery that improve patients’ quality of life while containing healthcare costs. HealthCare Partners man-ages and operates medical groups and affiliated physician networks in Arizona, California, Nevada, Florida, New Mexico and Colorado. As of Sept. 30, 2013, HealthCare Partners provides integrated care management for approximately 760,000 managed care patients. - Read More at (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.
Immediate Opportunities in Torrance, CA:
Director, Special Projects, IPAResponsible for developing and implementing IPA market growth strategy; facilitating the integration of IPA networks into the HCP organization; identifying and define best operational practices, evaluate performance, and drive rollout across the organization. Requires a Bachelor’s degree; minimum of 3 years post-MBA expe-rience in top tier management consulting, investment banking, or corporate healthcare role.
Director, Special Projects, ContractingThis position will serve as a vital consultant in the development and execution of a variety of operational and contracting projects with company-wide impact. This position will interact extensively with senior executives across Contracting, Regional IPA Operations, Regulatory, Compliance, Claims, Finance, Credentialing, Care Management, Risk Management and other key DaVita Healthcare Partners teams. Requires a Bachelor’s degree; over 7 years experi-ence in health administration and operations with a health plan, medical group or IPA; Project Management and strategic planning experience; 5 years management experience; experience in health plan, medical group or physician contracting.
We offer a competitive salary and benefits program including Health, Dental, Vision, 401(k), Continuing Education, Tuition Reimbursement, free Basic Life and AD&D, free LTD, a gen-erous holiday schedule, and more.
For immediate consideration please apply online at www.healthcarepartners.com or send to CV to Carol Caputo, PHR, Recruitment Consultant at
Senior Director, Managed CareAdventist Health Managed Care is seeking an experi-enced managed care professional to support physician and home health contracting. The applicant will have system wide responsibility for negotiations of payer contracts and will collaborate in the development of strategic initiatives related to physicians and home health. A minimum of 5 years experience in successfully negotiating various types of physician, IPA and home health managed care contracts, developing revenue growth opportunities and establish-ing strategic alliances is necessary. A Bachelor’s Degree is required; Masters Degree preferred. The position will be based in either Ontario, CA or Roseville, CA.
Qualified candidates should email their resume with salary history to [email protected].
For more information, please visit our website at: http://www.scanhealthplan.com/careers/
COMMUNITY OUTREACH REP (NORCAL) Req. #15-1807
DATA ANALYST SR. – HEALTHCARE SERVICES Req. #15-1840
DATA ANALYST SR. – HEDIS & MEDICARE STAR
Req. #14-1521, 15-1694
DIRECTOR RISK ADJUSTMENT PROGS & AUDIT Req. #15-1827
HEALTHCARE INFORMATICS ANALYST II Req. #14-1588
HEALTH PROMOTION RN Req. #15-1805
MANAGER DIGITAL STRATEGY Req. #15-1744
MANAGER QUALITY ASSURANCE & TESTING Req. #15-1779
PHARMACY ANALYST Req. #15-1739
PROJECT MANAGER Req. #15-1812
PROJECT MANAGER SHARED SERVICES Req. #15-1774
RECOVERY SPECIALIST Req. #15-1735
REG’L DIRECTOR, NETWORK MANAGEMENT Req. #15-1729
SALES OPERATION SPECIALIST Req. #15-1821
HOT SQL DATABASE ADMINISTRATOR Req. #14-1591
TEMPORARY/TELESALES REPRESENTATIVE REQ. #15-1835
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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.
Vice President, ComplianceEnsure regulatory compliance with state and other government agencies related to the health insurance industry, Centene Corporation, and its business subsidiaries.Responsibilities: Ensure business unit and Centene Corporate are in compliance with state, federal program/insurance regulations, regulatory and state contract requirements. Maintain, track laws, regulations, contract documentations, amendments, and compliance measures. Develop policies, procedures, processes to comply with state/federal law, contract requirements, and standards. Oversee, administer, and implement compliance programs, including fraud and abuse and HIPAA. Provide guidance to departments regarding compliance issues, implementation of new requirements.Education/Experience: Bachelor’s degree in Public Policy, Government Affairs, Business Administration or related field. Master’s or Law degree preferred. 8+ years compliance program management, contract experience. Extensive knowledge of state administrative code, regulations, state insurance laws, regulations including managed care regulations. Experience with state/federal government agencies, accreditation bodies, participating provider agreements, HIPAA and Third Party Administration (TPA) laws, credentialing regulations and prompt pay laws.Please submit your resume to [email protected]
Director, Medical ManagementDirect 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 [email protected]
CONTACT SUSAN: PHONE: [email protected]
You’re in Good Company When You Advertise in California Healthfax!
Place your ad today!
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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 employ-ees. 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, Network Management #321560Bachelor’s degree or equivalent/relevant experience required. Master’s degree preferred. Minimum 10 years of experience in a managed care environment with IPA’s, medical groups or HMO’s. 5 years direct experience in a Provider Relations role.
Executive 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, Regional Clinical Ops North # 321312 Bachelor’s degree in Business Management, Health Care Administration, Nursing or other related field required. Master’s Degree preferred. 10 years complex management experience in an ambulatory setting that includes experience and knowledge of medical practice and clinical management.
Director, Populations Health Analytics #323043Master’s degree in Computational Science or Economics, 5 years’ experience in healthcare finance, Population Health, ACO, Health Plan, medical management/cost of care or decision support environment; Proven quantitative and analytical skills. Experienced in the development of financial analysis, reporting, predic-tive analytics and claims systems.
OPERATIONS• Manager, Accounting• Practice Transform/Development Manager• Case Manager, ACO• Hospitalist Manager
• Director Accounting & Compliance• Manager, Lean Fellow• Manager, Material Services• Manager, MSO Collections
INFORMATION SERVICES• Director of Applications & Project Support• Clinical Applications Specialist (OpTime))
• Business Systems Specialist (Tapestry)• And many more----------
CLINICAL• RN In-Patient Care Manager• Clinical Risk Manager
• RN & LVN Supervisors• Practice Manager
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
Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. We serve over 1,000,000 members in Riverside and San Bernardino counties in Medi-Cal,Cal MediConnect Plan, Healthy Kids and a Medicare Special Needs Plan. Our success is attributable to our Team who share the IEHP mission to organize the delivery of quality healthcare services to our members. Join our dedicated Team!
CLAIMS QUALITY AUDITING SPECIALISTPossession of a High School diploma or equivalent. Two (2) years experience in examining and processing medical claims; Medicare/Medi-Cal experience.
Responsible for ensuring the integrity of all data created and updated by the Claims Processing staff. The QA Specialist will utilize Cost Management tools, identify training needs, and define effective and efficient methods for accurate data entry and adjudication. Review and assess data reports and audit Claims Processor output to confirm payment accuracy and completeness of data entry. Experience with Microsoft applications preferred. ICD-9 and CPT coding and general practices of claims processing. Professional demeanor, excellent communication and interpersonal skills, strong organizational skills. Prefer knowledge of capitated managed care environment.
DIRECTOR OF CALL CENTER SYSTEMS, QUALITY & TRAININGBachelor’s degree in Business Administration or related field, or five (5) years of equivalent work experience in lieu of degree. Previous experience with workforce and forecasting analysis utilizing industry software. Experience in a multi-skill, multi-site call/contact center operation is required. Experience with databases and/or data manipulation. Knowledgeable in call center operations including quality review and training experience. Highly organized with the ability to balance multiple projects and meet deadlines. Extensive experience writing policies and procedures and training documentation. Prior project management experience with the ability to work independently with the ability to develop concepts into business operations.
Five (5) or more years of healthcare call center experience working in a health care delivery setting. Experience in an HMO, managed care, knowledge in Medi-Cal, Healthy Families, Healthy Kids, and Medicare Programs preferred. Proficient in microcomputer applications. Excellent written and verbal communication, interpersonal skills, ability to establish and maintain effective working relationships with others, ability to supervise and train team member’s strong organizational skills, detail oriented, and sound decision making skills required. Ability to critically review data and implement operational recommendations. This role requires high degree of patience and strong ability to lead team members through inherent interpersonal challenges.
MEDICARE CLAIMS SUPERVISORPossession of a bachelor’s degree or equivalent work experience in a Managed Care or Health Care environment. Four (4) to six (6) years experience in a managed care environment in the areas of claims processing, and or provider payment appeals and disputes, with at least one (1) year in a supervisory capacity. A thorough understanding of claims industry and customer service standards. Prior Medicare experience preferred.
Extensive knowledge of ICD9, CPT and Revenue Codes. Solid understanding of the CMS and DHCS claim regulations, including AB1455. Principles and techniques of supervision and training. Analytical skills with emphasis on time management, database maintenance, spreadsheet manipulation, and problem solving. Strong writing, organizational, project management, and communication skills proficiency required. Must have a high degree of patience, excellent interpersonal and communication skills.
QUALITY ASSURANCE NURSE RN/LVN – COMPLIANCEPossession of a bachelor’s degree at an accredited four (4) year institution preferred. Possession of a RN/LVN California License. Three (3) or more years of demonstrated experience in an office environment, at a professional level, preferably in a Compliance function. Two (2) years experience in a managed care environment.
Demonstrated proficiency in Microsoft Office products (Word, Excel, PowerPoint, Outlook, etc.). Excellent interpersonal and communication skills, strong organization skills, ability to establish and maintain effective working relationships both within and outside of the organization. A wide degree of creativity and latitude is expected.
COMPLIANCE SPECIALISTHigh school diploma required. Possession of a bachelor’s degree at an accredited four (4) year institution preferred. Three or more years of demonstrated experience in an office environment, at a professional level, preferably in a Compliance function. Two (2) years experience in a managed care environment.
Demonstrated proficiency in Microsoft Office products (Word, Excel, PowerPoint, Outlook, etc.). Excellent interpersonal and communication skills, strong organization skills, ability to establish and maintain effective working relationships both within and outside of the organization. A wide degree of creativity and latitude is expected.
REPORTING ANALYST – COMPLIANCEPossession of a high school diploma or equivalent. Bachelor’s degree preferred. Five (5) years experience required in an office environment.
The Reporting Analyst will be responsible for providing support to the Compliance Department by developing, tracking, manipulating and monitoring reporting activities including working with the appropriate departments for regulatory reporting. Strong organizational skills and attention to detail. Proficient knowledge of Microsoft Access, Word and Excel required. Project Management experience preferred.
Please apply on-line: https://ww3.iehp.org/en/about-iehp/careers/
INLAND EMPIRE HEALTH PLAN Rancho Cucamonga, CA
Please visit our website at www.iehp.org