healthfax august 2011 - national health foundation

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PAGE 1 OF 5September 11, 2006

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August 29, 2011 | VOLUME 18 | NUMBER 33

T O P S T O R I E S

Senate Committee Approves Insurance Rate Regulation Bill Bill approved despite mounting oppositionThe state Senate Appropriations Committee last week approved a bill that would allow the state to regulate health insurance rate hikes.

In a 6-3 vote along party lines, the committee approved Assembly Bill 52, which would give the state power to reject health insurance premium increases it deems excessive. The bill will now move to the full Senate for a vote by Sept. 9. If the Senate approves the bill, it will still have to be signed by Gov. Jerry Brown, who hasn’t taken a position on AB 52.

Since it was approved by the state Assembly in June, opposition to AB 52 has mounted as groups including the State Department of Finance and the state’s Health Benefit Exchange expressed concern about the impact the bill could have.

In August, the Department of Finance issued an analysis that warned the state would incur “substantial first year and ongoing costs” if the bill is approved due to the need for “very large staff increases” to oversee rate hikes. It estimates that first year start-up costs for the Department of Managed Health Care (DMHC) would be $30.2 million with ongoing annual costs of $26.5 million. It also estimates the Department of Insurance would have $601,000 in start-up costs and ongoing annual costs of $957,000. The DMHC will have a much larger role due to its oversight of the state’s massive HMO market.

“Finance is opposed to this bill because the large amount of rates that would have to be reviewed would require very large staff increases that are likely to be impractical to achieve,” the report stated. “Thus, the state’s regulators could create an approval backlog resulting in no coverage for a large number of Californians.” The report also suggested that “should this bill pass as written, it would likely be challenged and the cost of litigation would be significant.”

The California Public Employees Retirement System (CalPERS) said it will oppose the bill unless it’s exempted from its provisions. The group is con-cerned about how it would impact its management of a program with 1.6 million members statewide. And the board of directors for the state’s Health Benefit

Editor’s note: In observance of Labor Day, California Healthfax will not publish on Monday, Sept. 5 and will resume publication on Sept. 12. We hope you have a great holiday weekend.

OF 12 August 29, 2011

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T O P S T O R I E S CONTINUED FROM PAGE 1

» Ventura Community Memorial Hospital plans to break ground in September on a new replacement hos-pital. Hospital officials finalized a bond-financing arrangement in mid-August to secure funding for the $268 mil-lion project through private lenders and will pay off the loan over 30 years. The new 250-bed hospital will meet state seismic safety standards and is due to open by 2015. The replacement hospital will be built directly behind the existing Ventura Community Memorial Hospital.

» WellPoint Inc. announced that it has completed the acquisition of CareMore Health Group, a pro-vider of Medicare Advantage plans based in Cerritos. CareMore serves approximately 54,000 members in California, Arizona , and Nevada through Medicare Advantage plans and its 26 Neighborhood Care Centers. “We are extremely pleased to finalize our agreement even sooner than antici-pated,” said WellPoint president and CEO Angela Braly. “This means we can now focus on the most exciting part of the acquisition, which is expanding CareMore’s proven system of providing Medicare recipients with high quality, personalized care that improves their lives and well-being.”

» The St. Joseph Health System Foundation will donate a total of $2 million in grants to 36 non-profit organizations in California for pro-grams that focus on wellness and pre-vention. The grants will range from $20,000 to $100,000 and will fund initiatives to improve healthcare access,

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Exchange in August raised concerns about how the bill would impact rates on the Exchange.

The California Association of Health Plans (CAHP), a trade associa-tion representing insurers in the state, cited growing opposition to AB 52 as further evidence that it should not be approved. “Although AB 52 has moved to the Senate floor, it is clear the wheels on this misguided proposal are com-ing off in the closing weeks of the legislative session,” said CAHP president Patrick Johnston. The California Medical Association and California Hospital Association have also come out against AB 52.

The bill authored by state Assembly Member Mike Feuer (D-Los Angeles) won approval in the state assembly by a 45-28 vote along party lines in June and was approved by the Senate Health Committee in July. Key supporters of the measure include state Insurance Commissioner Dave Jones and advocacy group Consumer Watchdog.

Consumer Watchdog issued a report last month noting that 1.53 million state residents saw their health insurance premiums increase in July. It cited the increases as further evidence that the state needs more power “to stop arbitrary and unnecessary rate increases.” Supporters also note that 35 other states have policies in place that allow state regulators to reject rate hikes.

The state currently has the power to review rate hike requests from insurers but does not have the power to reject them. State officials do have authority to reject rate increases for auto and property insurance that was granted in 1988 when voters approved Proposition 103. —DOUG DESJARDINS

Program to Reduce Hospital Infections off to Good StartRate of ventilator-associated pneumonia falls 41%A statewide program to reduce hospital-related infections has produced strong results in its first full year.

The Patient Safety First program was launched in January 2010 at 160 hospitals in California and targeted reducing hospital-acquired infections and other avoidable problems. During the first year, participating hospitals reported a 41% reduction in ventilator-associated pneumonia, a 25% reduction in central line blood stream infections, and a 24% decline in catheter-associated urinary tract infections. The effort also reduced birth traumas and elective deliveries among pregnant women prior to 39 weeks of gestation.

Insurance Regulation Bill cont.

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I N B R I E F Continued from page 2

women’s health, food assistance, oral health, chronic diseases, children’s health, homelessness, and emergency assistance. “As a faith-based organi-zation, we are committed to being an active partner in the communities that we serve by helping address the unmet health needs of California’s most at-risk populations,” said Gabriela Robles, executive director of the Orange-based SJHS Foundation. “During these eco-nomically troubled times, we are com-mitted to extending our support beyond the walls of our hospitals. The organiza-tions that receive these grants will help us achieve that goal.”

» California Pacific Medical Center (CPMC) has altered the design of a $1.7 billion hospital it plans to build in the Cathedral Hill section of San Francisco. The changes were made at the request of the San Francisco Planning Commission, which wants the hospital design to be more com-patible with historic buildings nearby on Van Ness Avenue. The changes include making the hospital design sym-metrical instead asymmetrical, breaking up the bulk of the structure by using a variety of materials including stone and glass for the building façade, and placing the entrance in the center of the building instead of the corner. CPMC officials are still negotiating with San Francisco Mayor Ed Lee on a plan to mitigate the impact the hospital will have on the nearby community. The hos-pital is due to open in 2015.

» The Cal i forn ia Hea lthCare Foundation (CHCF) has appointed




Patient Safety First program cont.

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Program coordinators said the sharp reduction in infections was due mainly to extra training and the exchange of best practices among hospital personnel.

“First year results show that this type of collaboration works,” said Eugene Grisby, MD, president of the National Health Foundation, which collected data from the hospitals. “Lives are being saved, incidents of hospital-acquired infec-tions are being reduced, and savings are being achieved.”

The three-year, $6 million program is being funded by Anthem Blue Cross and coordinated by three regional hospital associations, including the Hospital Association of Southern California (HASC), the Hospital Council of Northern and Central California, and the Hospital Association of San Diego and Imperial Counties. The job of the hospital associations was to provide hospital staffs with training and instruction on best practices for reducing infections.

“Our main contribution was selecting the categories of care and the col-laborative training experience,” said Jim Barber, president of HASC. “And much of the training involved face-to-face meetings and panels where ideas were exchanged among experts and the staff members of hospitals participating in the program.” He said additional training was provided online through Webinars and follow-up emails.

Many of the procedures that produced the strongest results - the 41% reduction in ventilator-associated pneumonia - were fairly simple. They included keeping patient beds elevated at a 30-degree angle to help keep the patients’ airways clear and improving oral hygiene to reduce the chance of deadly bacteria building up in a patient’s mouth and causing an infection. In many hospitals, that was achieved by having nurses and therapists swab the mouth of patient’s on ventilators with hydrogen peroxide four times a day.

Art Sponseller, president of the Hospital Council of Northern and Central California, said the results are a clear indication that “the best way to improve patient care is through peer-to-peer learning networks” and that “practical solu-tions, commitment, collaboration, and accountability are critical in addressing barriers to improvements.”

The National Health Foundation estimates that improvements made under Patient Safety First in 2010 saved 800 lives and $11 million in avoidable hospital costs. “This is money that would have been used to care for patients who would have developed sepsis and other hospital-acquired infections if they had not been able to avoid illnesses as a result of this shared learning.”

Barber said that, overall, HASC was “happy with the results, though we’re never satisfied until we get to zero.” He said the results were especially impres-sive given that they were made in just 12 months and added that “it will be interesting to see the results from the second year and whether they flatten or continue to improve.”—DOUG DESJARDINS

PAGE 3 OF 12 August 29, 2011

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I N B R I E F Continued from page 3

Sandra Shewry as its director of state health policy. Shewry will over-see the foundation’s Sacramento State Health Po l icy Off ice . Shewry is now president and CEO of the Center for Connected Health Policy and previously served as direc-tor of the California Department of Health Care Services. “Sandra’s broad knowledge of California’s health-care system and her previous senior leadership experience within three different administrations make her uniquely qualified to lead the founda-tion’s state health policy work,” said Mark D. Smith, MD, president and CEO of the CHCF. Shewry will join CHCF in early September.

» Marin General Hospital in Greenbrae is offering patients with insurance a 25% discount for paying their bills on time, according to a report in the Marin Independent Journal. The hospital is also offering patients who don’t have insurance with discounts of 40% for paying their bill at the time of service or by the due date. “We’re trying to make it an amount that is reasonable for them to pay,” said Marin General CFO David Cox in an interview with the Marin Independent Journal. “Also, when they pay quickly, it saves us a lot of money on the back end because we don’t have to do all the billing.” He said the 25% discount for patients with insurance typically applies to people who pay their bills at the time of treat-ment or when they are discharged from the hospital.




Report Provides Options for Health Benefit ExchangeCHCF stresses need for balanced approachThe California HealthCare Foundation (CHCF) issued a report suggesting state officials will need to balance a number of variables to create a successful health benefit exchange by 2014.

The report issued in August makes a number of recommendations for board members and other architects of the California Health Benefit Exchange (CHBE), which will serve as an online marketplace for consumers and small busi-nesses to purchase health insurance. The Patient Protection and Affordable Care Act (ACA) calls for each state to create an Exchange but does not dictate how they should be structured.

“An early challenge for CHBE will be to secure its identity in two distinct worlds,” the report states. “The exchange will operate simultaneously as a public entity entrusted with implementing ACA’s provisions and as a marketer of insur-ance plans that must attract health insurance carriers and consumers alike.”

The report outlines three different directions the state can take in creating an exchange. The first would establish it as Price Leader that “would prioritize affordability and low premiums.” The second would position it as a Service Center that provides “one stop shopping with broad choices in plan design, detailed consumer information, and a high level of customer service.” And the third option would establish it as a Change Agent that would “focus on long-term system reform and on promoting innovation in the healthcare industry.”

Marian Mulkey, director of health reform and public programs for the CHCF, said the foundation is not promoting any one option. “None of the specific models is intended to be an operational blueprint,” said Mulkey. “Instead, they are intended to illustrate, at a high level, the strategic tradeoffs involved in pri-oritizing one outcome above the others.”

Mulkey said the likely outcome is that the Exchange will “incorporate elements of each model in its strategic planning” as the board works with state health offi-cials, insurance companies, and other stakeholders on establishing parameters.

The CHCF assumes most insurance companies in the state will participate in the Health Benefit Exchange. “I expect all of California’s major insurers, particu-larly those participating in the individual market today, to look very carefully at the new market opportunities presented by the Exchange - particularly the avail-ability of tax credits for low-to-modest income individuals available only through the Exchange.” —DOUG DESJARDINS


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» Sept. 19-21. Disaster Planning for California Hospitals. HyattRegency, Sacramento . A three- d a y g a t h e r i n g f o r h o s p i t a l d i sas te r p reparedness coord i -nators that wi l l focus on new technologies and programs to help deal with catastrophic incidents. Sponsored by the California Hos- p i ta l Assoc iat ion . To reg is ter , p l e a s e v i s i t h t t p : / / w w w .calhospital.org/disaster-planning

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I N B R I E F CONTINUED FROM PAGE 4

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E V E N T S


» UC Davis Health System and the California Telehealth Network are provid-ing 15 organizations with a total of $5 million in funding for telehealth programs. The Broadband Adoption Model eHealth Communities Awards will fund pro-grams that help improve access to care for residents in rural areas and under-served urban and suburban areas. The average award will provide $300,000 for the pur-chase of equipment and $50,000 for training and project management. Receiving awards are the Alameda County Health Services Agency, Access El Dorado, California Rural Indian Health Board, College of the Siskiyous, Community Hospital of San Bernardino, Connecting to Care Modoc County, Connecting to Care Sierra-Nevada, Center for Technology, Innovation and Well Being, Southern California, L.A. Care Health Plan, North Coast Clinics Network in Humboldt County, Plumas District Hospital, Redwood MedNet, Southern Sierra Telehealth Network, UC San Francisco, and Venice Family Clinic.

» California Attorney General Kamala Harris has joined attorneys general from nine other states in filing a Friend-of-the-Court Brief that supports the constitutionality of federal healthcare reform. The brief was filed with the Eighth U.S. Circuit Court of Appeals, which will review a lawsuit that challenges the healthcare reform law. In the brief, Harris states that healthcare reform “strikes an appropriate, constitutional balance between federal and state authority over the healthcare system.” Also filing briefs were attorneys general from Connecticut, Delaware, Hawaii, Iowa, Maryland, New York, Oregon, Vermont, and the District of Columbia.

» The president and CEO of health information exchange Cal eConnect has stepped down. Carladenise Edwards left the non-profit exchange after 13 months on the job but will continue to serve Cal eConnect as a senior advisor. “Dr. Edwards has done a great job of getting our ‘start-up company’ off the ground in a complex and uncertain environment,” said David Lansky, co-chair of the Cal eConnect board of directors. “Launching a new organization of this caliber in such a short timeframe has been an enormous accomplishment.” In a statement, Edwards said the decision to step down was the “best decision for my family, the organization, and the state of California” and that she will “continue serving the organization as we transition to a new phase.”

» State lawmakers last week approved a resolution urging the federal government to help California increase its supply of physicians. The state Senate voted 24–10 in support of Assembly Joint Resolution 13, which encourages federal lawmakers to consider solutions such as increasing the number of graduate medical residency positions in California to keep pace with a growing need for physicians. “Our state is barely meeting the recommended supply of primary care physicians and those numbers are unevenly dispersed throughout the state, leaving some communi-ties without access to care for miles,” said James Hinsdale, MD, president of the California Medical Association.

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PAGE 6 OF 12FAugust 29, 2011

F E A T U R E D O R G A N I Z A T I O N



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

PAGE 7 OF 12August 29, 2011

(Continued next page)

HOSPITALIST (Tucson, AZ / Los Angeles, CA / High Desert, CA / Modesto, CA)

The Hospitalist provides Internal Medicine Services to patients. Responsibilities include: Round in the hospital in the mornings and sees an average of 6 to 10 patients. Conference calls with Case Managers to review patients, and discuss the discharge needs and plans. Admit the patients from the ER in the afternoon (usu-ally 2 to 4 patients), if they are assigned ‘float’ position for the given day. Work with Case Managers in transferring the patients from ‘out of area’ hospitals into network hospitals. See patients in the CareMore Care Center (CCC). All patients discharged from the hos-pital are seen by the Hospitalists in the clinic until they are stabi-lized. Patients with falls are assessed. Pre operative clearance is done on patients undergoing surgeries requiring general and spinal anesthesia. Assist Nurse Practitioners by reviewing the cases with them. See the ‘skilled’ patients in the SNFs. These patients are seen once a week until they remain skilled, which is normally from 1 to 2 weeks. Attend the SNF meetings once a week to review the cases. Education and/or Experience: Internal Medicine Residency, Medical Doctorate, and minimum of 2-3 years of Hospitalist experi-ence preferred. Bilingual Spanish preferred. Certificates, Licenses, Registrations: Medical License in the state in which you are applying, DEA license. Must be board-certified or board eligible in specialty.

CLAIMS AUDITOR (Cerritos, CA)

The Claims Auditor oversees the company’s adherence to policies and procedures to federal and state laws and regulations. Coordinates, supervises and supports compliance related programs and informs and advises management of conditions and status of adherence to laws and regulations. Education and/or Experience: Bachelor’s degree pre ferred; or 1-2 years related experience and/or training; or equivalent combination of education and experience. 3 years of claims compliance experience.

NURSE PRACTITIONER(Los Angeles, CA / San Jose, CA / Tucson, AZ)

CareMore’s Nurse Practitioners are the lead care managers for patients with chronic conditions. They provide exceptional care to our members in our Care Centers, and other care environments. Education and/orExperience: Masters Degree in Nursing required. Certificates, Licenses, Registrations: Current NP certification, RN license, Furnishing and DEA licensure in good standing as required in the state in which you are applying.

TOUCH NURSE PRACTITIONER (Cerritos, CA)

The Touch Nurse Practitioner ensures effective and efficient treat-ment of our Touch members. This individual will be responsible for

managing patient care at multiple facilities through the implementation of cohesive and efficient processes, with emphasis to include patient and family satisfaction and physician and facility support. This indi-vidual provides general medical care and treatment to members in institutionalized settings such as nursing homes, assisted livings, or board & care facilities, under the direction of the Physician. Education and/or Experience: Masters degree in Nursing with emphasis in Family, Adult, or Gerontological practice. Certificates, Licenses, Registrations: Current registered nursing license and Nurse Practitioner license in good standing with your state.

CONTRACTING/CREDENTIALING SPECIALIST (PRACTICE MANAGEMENT OPERATIONS)

(Cerritos, CA)

The Credentialing Specialist will be responsible for reviewing new and existing health plan and IPA agreements to ensure results are favorable to the individual physicians of the medical group. This role is responsible for enrolling, adding and or credentialing new physi-cians of the medical group with FFS plans, Medicare and Medi-cal. Responsibilities will also include maintaining physicians’ files and processing license renewals, change of address, status and/or name changes, process dues and re-appointments for physicians of the medi-cal group. This role will also support the business office with payment disputes and resolution as well as assist departmental management staff with any and all credentialing related issues and special projects. Successful candidate must be a self-directed individual with excellent written/verbal communications skills, MS Office proficiency, and supe-rior organizational skills. Education and/or Experience: Minimum high school diploma, 2–4 years experience in the field.

REGIONAL PERFORMANCE MANAGER (N. Orange County, CA)

This position is responsible for negotiating, implementing and managing capitated and fee-for-service agreements with individually contracted PCPs, medical groups, IPAs and specialists in an assigned region. Additionally, the position is accountable for training and orienting all providers and providing best in class customer service to PCPs, specialists and local ancillary providers. Position requires a strong understanding of reimbursement methodologies, contract lan-guage, negotiation strategies, financial modeling and analysis, managed care and Medicare Advantage plans. Education and/or Experience: Bachelors degree or equivalent experience. Other Qualifications: Minimum of 5 years managed care contracting experience.

IT FACILITIES OPERATIONS LEAD (Cerritos, CA)

The primary role of the IT/Facilities Operations Lead position is to provide leadership and delivery of key IT and facilities opera-tional areas which include: IT/Business facilities integration, facilities management and implementation, vendor management, and require-ments and implementation of core IT infrastructure (desktop, IT plant management, telecommunications). This role serves as the primary IT/Facilities liaison and interface to our expansion region customers. Education and/or Experience: Bachelors degree





and over 5 years related experience or equivalent combination. Other Qualifications: Knowledge of current trends in IT and facili-ties management. Demonstrated experience with standard software applications, including MS Office, Windows. May require database management skills with ability to produce reports. Ability to mani-pulate, analyze and interpret data. Familiarity with support andtroubleshooting. Experience with facilities management and/or imple-mentation. Must exhibit exceptional customer service. Trainingability/experience a plus.

PSYCHIATRIC NURSE PRACTITIONER (Los Angeles, CA / Tucson, AZ)

The Psychiatric Nurse Practitioner provides general medical care and treatment to patients in medical facilities such as the clinic,health center, or public health agency, under the direction of the Physician. Education and/or Experience: Masters of Science in Nursing. Certificates, Licenses, Registrations: Current NursePractitioner license in good standing with the state in which you

are practicing. Other Qualifications: Psychiatry Training or Neuropsychiatry Subspecialty.

CASE MANAGEMENT NURSE(Cerritos, CA / Tucson, AZ)

The Case Manager collaborates in a patient care process to assess, plan, implement, coordinate, monitor, and evaluate options and ser-vices to meet member’s health needs. The goal of the Case Manageris to utilize available resources to provide quality, cost effective careusing selective benefits and alternative services best suited for themember while ensuring optimal outcomes. Certificates, Licenses,Registrations: Current Registered Nurse license in the state which you are applying for. Other Qualifications: Must have at least 2 years :experience in acute hospital care preferably in the discharge planning or medical review areas, Utilization Review/Case Management experi-ence in a hospital and/or medical group setting is desirable, and knowl-edge of managed care (HMO, PPO, POS, etc.) is preferred.

To submit your CV/Resume for consideration:

Visit http://www.caremore.com/en/p About/Careers.aspxp to apply online.

For more information about CareMore please visit www.caremore.com

COMPLIANCE SPECIALIST/ADVISOR

Ensures that L.A. Care and its Plan Partner provider network are compliant with all product line (Medi-Cal, Medicare, HealthyFamilies, Healthy Kids) program contractual, state and federal regu-latory requirements. This is achieved by participating in the annual Plan Partner audits, working with Plan Partner staff to correct performance deficiencies, identifying internal areas for improve-ment, through conducting internal audits, serving as the compliance contact with Plan Partners for member grievance oversight for all product lines, and interpreting Medi-Cal and other product lineprogram requirements for L.A. Care and its contracted entities.Additionally, this individual is a resource to internal staff on all prod-uct line compliance matters and performs internal audits as required and monitors Member Grievances, as well as Claims compliancestandards for appropriateness. Working knowledge of DHCS, DMHC, and CMS requirements is required, as well as highly developed analytical and critical thinking skills. Excellent written and oral com-munication skills are essential. Juris Doctorate is a strong plus.

For the complete job description, qualifications/requirements, and other opportunities, visit our website: www.lacare.org

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DIRECTOR, PATIENT BUSINESS SERVICES/REVENUE CYCLE

Manages revenue cycle process from point of service to account resolu-tion. This person will provide leadership and oversee daily operations ($520 million net patient revenue with departmental budgets includ-ing 72 fulltime employees, $12.3 million in direct expense for PatientB i S i (PBS) R i t ti d Fi i l C li ) Cit f





PROJECT MANAGER-HEDIS (Long Beach, CA)

JOB SUMMARY: Support the Quality Initiatives Team andHealthcare Informatics in activities related to quality improvement,measurement, reporting and analysis.

ESSENTIAL JOB RESULTS: Manage all aspects of HEDIS data col-lection including but not limited to abstraction, report submissions,audit activities, and adherence to HEDIS timelines and performancegoals. Hire, train and supervise temporary HEDIS staff.

Identify data sources and ensure the timely retrieval, accuracy andcompleteness of the HEDIS data repository. Develop medical data chase logic based on comprehensive analysis of prior years’ chase schema. Collaborate with other departments and staff on projectimplementation to maximize efficiency and teamwork. Monitor proj-ect progress and budget and provide weekly status update to man-agement; implementing corrective action plan as necessary. Submit all HEDIS reports including those for Special Needs Plans as requiredby CMS and DHCS.

Conduct comprehensive post-HEDIS analyses to assess barriers,gaps, and opportunities for improvement. Educate network providerson evidence based clinical guidelines and best practices to improvequality of care and service for members through webinars, on-sitemeetings, mail and electronic correspondence. Conduct targeted member and provider outreach and education via electronic data exchange, phone calls/IVR, mailings, etc. Utilize HEDIS/HOS/CAHPSmeasure indicators to monitor and improve clinical and service deliv-ery processes and outcomes. Maintain professional and technical knowledge by conducting research and by attending educational andtechnological workshops. This position requires contributions to teameffort by accomplishing and sharing related results with other staff. Contribute to team effort by accomplishing related results as needed.

QUALIFICATIONS: Bachelors or Masters degree in health care or related area with emphasis in quantitative data analysis. Experiencein quality improvement and HEDIS project management. Moderate tostrong knowledge in processing of claims, encounters, and pharmacydata. Proficient in SAS/SQL programming. Proficient in MicrosoftOffice applications. Strong verbal and written communication skills with the ability to express ideas in a clear and organized manner.

PROJECT MANAGER-QUALITY INITIATIVES (Long Beach, CA)

JOB SUMMARY: Support the Quality Initiatives Team and Healthcare Informatics in activities related to quality improvement,measurement, reporting and analysis.

ESSENTIAL JOB RESULTS: Assist in the design and execution of quality initiative programs, and evaluate effectiveness. Cross train with QI analysts to identify barriers and perform root cause analysesand propose solutions related to quality initiatives. Work with internalbusiness users and contracted provider network to ensure compliancewith CMS and DHCS quality standards. Prepare clear and concisereports and presentations for committee and departmental meetings.Update and maintain quality improvement program documents, workplan, and annual evaluation. Share responsibility for data analytics and project management related to CMS Star initiatives.

Demonstrate flexibility and ability to multi-task when assigned otherprojects and tasks.

Maintain professional and technical knowledge by conducting researchand by attending educational and technological workshops. Thisposition requires contributions to team effort by accomplishing andsharing related results with other staff. Contribute to team effort byaccomplishing related results as needed.

QUALIFICATIONS: Bachelors or Masters degree in health care or related area with emphasis in data analysis. Proficient in SAS/SQL programming and health care analytics. Strong project manage-ment skills. Proficient in Microsoft Office applications. Strong verbaland written communication skills with the ability to express ideas ina clear and organized manner. Strong organizational and timemanagement skills to efficiently handle multiple projects with chang-ing priorities.

Both of these positions are FT, M-F 8 AM to 5PM, with extendedworking hours and occasional travel as needed.

Apply to www.scanhealthplan.comp – Job Opportunities – Req. # 11-415 (Project Manager – HEDIS), or Req. # 11-411 (ProjectManager – Quality Initiatives)

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[email protected]. By phone: 415/259-4848.For other questions, contact Bob Wertz, Managing Editor. By phone: 800/639-7477, ext. 3456. By e-mail: [email protected]

December 31, 2009 | VOLUME 16 | NUMBER 46

ADVERTISING OPPORTUNITIESTo advertise in California Healthfax,please contact Bill Clattenburg. By

e mail: bclattenburg@healthleadersmedia com By

2009: The Year in ReviewThis is placeholder copy for the 2009: The Year in Review to be distributed on

Thursday, December 31. While health reform faltered in the receding economy, therewere bright spots in disease management, health IT, patient safety, and access to care for the poor, elderly, and uninsured. The fiscal crisis stalled passage of a new $141billion budget for 81 days, draining state coffers as lawmakers managed to eliminatea $15.2 billion deficit only to face a new shortfall estimated at $14.2 billion by mid-2009. State regulators cracked down on HMOs for rescinding policies of membersafter they sought medical care and banned the provider practice of balance billingwhere patients are charged for disputed sums. A state pay-for-performance initiative raised the bar on quality of care and awarded $65 million to high-achieving physiciangroups. As 2008 waned, fiscal pressures halted some hospital expansion and seismicupgrade projects, caused cuts in county health programs, and pushed the number of uninsured to 6.3 million. Foundations helped fill gaps, awarding more than $100 mil-lion to support clinics for the poor and disadvantaged and to advance technologiesand workplace safety. The California Endowment gave $7.5 million to help keepHealthy Kids afloat in 32 counties while First 5 California donated $16.8 million so Healthy Families California can enroll children through June of ‘09, and the fiscally pinched state is stalling on paying $8 billion to a prison overseer to rebuild dilapidated hospitals and clinics for inmates, setting the stage for a funding battle in U.S. DistrictCourt. I hope you enjoy this peek at the Year In Review, and I’m atop the lookout wwperch of California Healthfax to report on the achievements, challenges, and changing

s of California’s $1 trillion healthcare industry in what is shaping up to be ay supercharged 2009. — JOHNJJ LN EIGHTY, YY EDITOREE , CRR ACC LIFORNIA HEAHH LTHFAX

This special year end issue of California Healthfax

is sponsored by Monarch Healthcare, please see

their ad on page 6 for valuable career opportunities

with this premier organization.• • • • • • • • • • • • • • • • • • • • • • • • • • • • • •




PAGE 6 OF 13FDecember 31, 2009

Monarch HealthCare is a medical group (“IPA”) of over 2500 independent physicians in private practice dedicated to prac-ticing medicine the way it was meant to be. Monarch HealthCare is owned and operated by doctors who believe in working collaboratively with all stakeholders to improve the delivery of healthcare in the communities we serve. We are an industryleader in providing coordinated care! Our commitment to our employees and our employee dedication to our physicians andleader in providing coordinated care! Our commitment to our employees and our employee dedication to our physicians and patients is what differentiates us.

Monarch HealthCare is currently searching for exceptional candidates for these available career opportunities:

EXPERIENCED MEDICAL DIRECTOR, OUTPATIENTSERVICES: In this high profile position you will be taskedwith the following: interacts with physicians, health plan staff, Associated Medical Directors, and health plan mem-bers when a physician’s input is needed or required. The Medical Director, Outpatient Services is responsible for theMedical Management Function, which includes ReferralManagement, Case Management and Disease Management Programs, as regulatory agencies require and the IPA’s plancontracts stipulate.

In this collaborative role, you will partner with the Senior Medical Director along with the VP of Clinical Services inorder to create a leadership model that joins our Physicianswith our business leaders to exemplify Monarch’s quality and performance standards.

Our Medical Director, Outpatient Services will work in con-cert with various levels of management to successfully perform as a consultative arm to our Clinical Services and Case Management Departments, Utilization ManagementCommittee, Member Services, Finance and provide policy planning and development.

Our ideal candidate for this exceptional career opportu-nity will be a graduate from a national accredited School of Medicine or Osteopathy; a doctoral degree (MD or DO);greater than 5 years related experience and/or training; or equivalent combination of education and experienceincluding 3 years of clinical practice in direct patient care; and at least 3 years medical management experience in a managed care setting. In addition, the successful candi-date will possess sufficient clinical knowledge to interactwith the physician members of the IPA in all major medical specialties. Candidate must hold a valid, unrestricted licenseto practice medicine in the State of California along withboard certification in their chosen specialty and a strong desire to work in tandem with Clinical Leadership to design, develop and execute special programs including correc-tive action plans. Candidates with a proven track record of quality leadership and exceptional teamwork in order to build and foster stellar working relationships in both Clinical andOperational departments are strongly desired.

ELECTRONIC HEALTH RECORDS IMPLEMENTATIONSPECIALIST: Responsibilities for this highly dynamic role include the implementation, configuration, training, and re-engineering of practice operations to support the successful adoption of an electronic practice management and electronic medical records software. Must be able towork in partnership with team members, physicians and their staff to design, configure, test, train, implement and support the use of the EHR software. Qualifications for this exciting opportunity include: Prior experience implementing and train-ing an electronic health records system in a physician office setting or hospital setting. Strong ability to work as a collab-orative member of a team. Demonstrate ability to grasp new technologies. 3–5 years experience in a similar role preferred.

REVENUE RECOVERY ANALYST—HOSPITAL CLAIMS:Responsibilities for this detail oriented position include the review and analysis for risk pool medical payments.Additional responsibilities will include timely reconciliation of capitation deductions, submission of stop loss recoveries tocarriers and audit of payments received to ensure maximumrecoveries and cost savings. Qualifications for this detail driven position include: 3 to 4 years related experience or 4 to 5 years prior experience in a medical claims processing or auditing environment. Prior experience in a managed caresetting preferred.

Monarch HealthCare has assembled a competitive compen-sation package that recognizes the many contributions by our dedicated employees and strives to keep our employeesas satisfied, long term business partners! Our competitivesalary, robust employee health plans, generous retirementpackage and “work-life balance” vacation schedules are the cornerstone of our employee friendly health and wel-fare plans! To join the best IPA in Orange County, send acurrent resume to [email protected],@ , where great careers begin! For more information on these positions and all of our available career opportunities, please visit ourwebsite at www.monarchhealthcare.com.

Monarch HealthCare would like to wish a Happy Holiday Season and all the best in the New Year

to our employees, partners and members!

• Banner featuringyour logo on thecover of the issu

• A full page, first page ad in the featureddisplay ads

Sherman Oaks Hospital, an affiliate of Prime HealthcareServices, is currently recruiting for the following opportunities:

CHIEF FINANCIAL OFFICER

JOB SUMMARY: The Chief Financial Officer is responsiblefor all financial and fiscal management aspects of company operations. Provides leadership and coordination in theadministrative, business planning, accounting and budgetingefforts of the company.

QUALIFICATIONS: Master’s Degree in Health CareAdministration, Hospital Administration or an MBA/CPAwith related health-care management experience. Extensiveknowledge of Healthcare Financial practices and principles.Minimum of 8 years experience in hospital or healthcare set-ting required. Familiarity with computer accounting/financial programs.

If you are a controller looking to move up to CFO please apply.

DIRECTOR OF HIM (Multiple locations)

JOB SUMMARY: The Director is responsible for planning,organizing and influencing department activities and endur-ing maintenance of hospital medical records while maintain-ing continuous quality improvement. The Director maintains operations within budgetary parameters. Effectively interactswith patients, their significant others and other health teammembers, while maintaining standards of professional service.

QUALIFICATIONS: Must be knowledgeable regarding the Health Information Management Department process and its application and evaluation of qualitative issues. 3–5 yearsexperience in a HIM Department, in an acute care setting required. Minimum 2 years HIM management/supervisory experience required. Successful completion of college level courses in anatomy, physiology, medical terminology and cod-ing, ICD and CPT; required. Successful completion of an edu-cation program for Registered Health Information Technician(RHIT), or Registered Health Information Administrator(RHIA) required. Must possess current certification/license as a Registered Health Information Technician (RHIT),or Registered Health Information Administrator (RHIA).Bachelor’s Degree or Master’s Degree in a related field pre-ferred. Acute HealthCare Experience is required.

Prime Healthcare offers a competitive compensation package and excellent benefits in a growth-oriented

environment. Please send resume to Chris Hoffman at [email protected]





Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. We serve over 485,000 members in Riverside and San Bernardino counties in Medi-Cal, Healthy Families, Healthy

Kids, and a Medicare Special Needs Plan. Our success is attribut-able to our Team who share the IEHP mission to organize the delivery of quality healthcare services to our members. Join our dedicated Team!

BUSINESS ANALYST COMPLIANCE

Under the direction of the Director of Compliance, the Business Analyst will actively participate in developing and implement-ing the software selected to support organizational compliance. Will maintain data integrity with the compliance software and perform all related reporting and analysis functions. Responsible for assisting with regulatory compliance filings and the analysis and distribution of the Medi-Cal Website updates. Analytical skills with emphasis on data reporting and analysis. Accuracy in work product, time management, regulatory interpretation and problem solving skills. Thorough knowledge of DMHC, DHCS, MRMIB, CMS, and related regulations preferred. Experience in Microcomputer applications (Word, Excel and Access). Minimum of 2 years experience in a managed care environment. Emphasis on the application of technology, Medicare compliance and project management preferred. Bachelor’s degree required. Valid State of California Driver’s License.

QUALITY IMPROVEMENT & RESEARCH MANAGER (HEDIS/P4P)

Responsible for the development, coordination and implementa-tion of all HEDIS, CAHPS and HCC-related improvement projects. Monitoring and measuring the progress of all selected improve-ment plans and for measuring the performance/outcomes of such efforts on a continual basis. 2 or more years experience in Statistical and Research Methods or HEDIS Reporting and Improvement activities at a Health Plan level. Bachelor’s degree in a health-related field from an accredited 4 year institution required. Master’s degree in Business or health related field is pre-ferred. Possession of a valid State of California Driver’s License.

NURSE MANAGER, GRIEVANCE, RN

Under the direction of the Director of Quality Management, the Grievance Manager is responsible for the direction and over-sight of all medical and non-medical Grievance Unit activities and personnel to ensure Member grievances are solved accurately and timely. Valid CA RN license and Bachelor’s degree with a major in Business or Healthcare Administration from an accredited 4 year institution required. Minimum of 3 years of supervisory experience required.

IEHP offers a competitive compensation and benefits package. Interested applicants should email

their resume to [email protected]. Please visit our web site at www.iehp.org. EOE.

PROJECT MANAGER

L.A. Care is seeking a dynamic Project Manager (for a 24 month project) to support the implementation of the Safety Net eConsult program and the California Telehealth Network (CTN) Model eHealth Community Project. The CTN & eConsult Project Manager will support the Health Information Technology (HIT) Program Manager in develop-ing and overseeing project plans for the implementation of eConsult technology in at least 47 clinics in the Los Angeles area. This Project Manager will work closely with L.A. County Department of Health Services in this county wide effort and will be responsible for coordinating project tasks related to the eConsult and the CTN grant projects.

The candidate will also conduct assessments and analysis for community clinics in the Los Angeles area in order to facilitate the implementation of eConsult and CTN grant projects into the clinic workflow. The Project Manager is responsible for building and maintaining relationships throughout the course of the projects. Qualified candidates should have a back-ground in working with PCP offices and health information technology. A Bachelor’s degree is required; PMP certifica-tion is preferred. Familiarity with grant management, a plus.

Please send all resumes to [email protected]

PROJECT COORDINATORS (2)

L.A. Care is seeking two eConsult Project Coordinators to coordinate project tasks related to the eConsult implemen-tation. The candidate will also conduct assessments and analysis for community clinics in the Los Angeles area in order to facilitate the implementation of eConsult into the clinic workflow. The Project Coordinator will report directly to the Health Information Technology Program Manager and will work with the eConsult Project Manager for project tasks. Qualified candidates should have a background in working with Physician offices and project management.

Some of the duties of the Project Coordinator are: Develop tracking matrix for clinic outreach and training efforts. Maintain clinic contact database. Build and maintain rela-tionships with stakeholders. Serve as a liaison between L.A. care and clinic offices. Develop training guides for eConsult implementation. Updating policies and procedures.

Required: 2 years experience in a health care setting. Strong outreach and educational skills. Strong problem solving and analytical skills. Strong public speaking and presentation skills. Proficiency with MS Office including Word, Excel, Access and PowerPoint and Adobe Acrobat. Preferred: Bachelor’s degree.

Please send all resumes to [email protected]



E M P L O Y M E N T O P P O R T U N I T I E S


PROVIDER SERVICES MANAGER

The purpose of this position is to shape and support Network Management’s mission of “service excellence”, defined as an efficient, consistent, effective and quality driven work prod-uct, through oversight of the operational interface between SCAN and its provider network. Successful applicant will have direct responsibility for development and maintenance of Provider Network relationships (hospitals and physician groups), and for the development/streamlining of work pro-cesses. Strengths that will ensure success in this position are change management expertise, a facility with technical and quantitative data, excellent team development and par-ticipation skills, and a passion for accountability and service excellence. Requirements: Management experience (5+ years preferred); Provider Services experience with an HMO or Provider (5+ years preferred); strong analytic, quantitative, and problem solving skills, and strong communication skills. BA/BS strongly preferred. Driving required.

Apply to www.scanhealthplan.com – About SCAN – Job Postings

ADVERTISE YOUR PRODUCTS

& SERVICESNOW!

PLACE YOURRECRUITMENT AD TODAY!

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EMAIL [email protected] or call 888/834-4678

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