top stories california providers bracing labor day monday...
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California providers Bracing for 10% Medi-Cal CutsCuts to be phased in from September to JanuaryThe state Department of Health Care Services (DHCS) next month will begin phasing in 10% cuts to Medi-Cal reimbursements for providers and will make the cuts retroactive to 2011.
DHCS officials said the 10% cuts will go into effect Sept. 5 for medical trans-portation and dental providers and will be followed by cuts for durable medical equipment and medical suppliers on oct. 24. The last wave will be implemented Jan. 9 for physicians, clinics, pharmacies, and distinct-part skilled nursing facilities.
“The staggered implementation is due to system changes that are neces-sary to implement the reductions,” said DHCS spokesman Norman Williams. “In categories where the system change is more complex, it will take us longer to complete the change.” The state estimates the cuts will generate cost savings of $724 million in fiscal 2015.
State health officials also plan to make the cuts retroactive to June 2011, when the cuts were originally scheduled to go into effect with the passage of Assembly Bill 97. But the state won’t start its recoupment plan until after all the cuts are implemented. State officials “are still developing the recoupment plan” but said the idea will be to recover the overpaid funds gradually by deduct-ing small amounts from future Medi-Cal payments.
A small number of providers will be exempt from the cuts. They include non-profit pediatric surgery centers that provide at least 99% of their services under general anesthesia to children with severe dental disease. Distinct-part skilled nursing facilities classified as “rural or frontier” will also be exempt from the cuts along with some high-cost prescription drugs that are used to treat chronic conditions such as multiple sclerosis. According to the California Hospital Association, 29 of the 98 hospitals in the state that operate distinct-part skilled nursing facilities are classified as “rural or frontier.”
Providers continued to criticize the cuts. The California Medical Association (CMA) said the cuts will reduce access to care for Medi-Cal patients
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» rady Children’s Hospital opened a new Cardiovascular intensive Care Unit (CICu) on Aug. 14. The unit will be staffed by physicians and nurses from the hospital’s pediatric intensive Care Unit and Neonatal intensive Care Unit and features state-of-the art equipment including an extracorporeal membrane oxygenation machine that circulates blood and provides it with fresh oxygen. The CICu will also provide a full range of lab services, radiology, and advanced patient monitoring. rady Children’s Hospital, a 446-bed pediat-ric hospital located in San Diego, has one of the busiest cardiac centers in California and performs nearly 500 sur-geries each year.
» The California Department of public Health (CDPH) has fined 10 California hospitals a total of $675,000 for safety violations. The fines range from $50,000 to $100,000 and were assessed for infractions that include an incident in which surgeons removed the wrong kidney from a patient with can-cer. receiving fines of $100,000 were Marin General Hospital in Greenbrae, Memorial Medical Center in Modesto, and St. Jude Medical Center in Fullerton. receiving fines of $50,000 were Alta Bates Medical Center in oakland, Barlow respiratory Hospital in Los Angeles, Desert Valley Hospital in Victorville, ronald reagan UCLA Medical Center in Los Angeles, Hollywood presbyterian Medical Center in Los Angeles, and UC Davis Medical Center . Sharp Memorial Hospital in San Diego received a fine of $75,000. All hospitals must submit
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by forcing some physicians and clinics to stop accepting new patients. The CMA said that “Medi-cal provider payment rates are among the lowest in the nation” and that the low reimbursements “have driven many California providers from the program.”
other critics say the cuts will come at a time when the Medicaid Expansion provision of federal healthcare reform will add more than 1 million new patients to a state Medi-Cal program that currently has more than 8 million members. “Many physicians in rural areas have been reluctant to accept new Medi-Cal patients because reimbursement rates were already low and expected to go lower,” said Gail Nickerson, president of the California Association of rural Health Clinics. “And with Medicaid Expansion kicking in at the same time, it’s scary.”
The 10% cuts were approved in 2011 but challenged and blocked by a pre-liminary injunction issued by a U.S. District Court judge in Los Angeles. The state appealed that decision to the Ninth U.S. Circuit Court of Appeals and a three-judge panel from the ninth Circuit vacated the preliminary injunction in December 2012, ruling that providers who accept Medi-Cal could not expect rates to never change. The CMA and other groups appealed the decision to the U.S. Supreme Court but the request was turned down.
Earlier this year, opponents of the cuts sponsored bills designed to block them. Senate Bill 640 authored by Sen. ricardo Lara (D-Long Beach) —which would have blocked 10% cuts to physicians, clinics and other providers—stalled during the committee approval process. But Assembly Bill 900 authored by Luis Alejo (D-Salinas) was approved in the state Assembly and has moved to the state Senate for consideration. AB 900 would block Medi-Cal cuts to all distinct-part skilled nursing facilities in California hospitals. —Doug DesjarDins
report Urges State to test programs Expanding role of paramedicspilot program expected to launch in 2014A new report suggests the state should launch pilot programs to expand the scope of service of paramedics to provide more targeted care for patients in emergency situations.
The report titled Community paramedicine: A promising Model for integrating Emergency and primary Care was compiled by the UC Davis institute for population Health improvement (IPHI). It recommends
California providers cont.
PAgE 2 of 14August 26, 2013
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a plan of correction with the CDPH designed to prevent future violations.
» Children’s Hospital & research Center oakland and the University of California at San Francisco (uCSF) Medical Center have signed an affilia-tion agreement that will allow the two hospitals to share services but remain separate entities. A joint letter sent to employees Aug. 8 called the affiliation agreement “the next milestone in estab-lishing a formal relationship.” The agree-ment, which is still subject to approval by state regulatory agencies and the university of California, is designed to allow uCSF and Children’s Hospital oakland to share medical specialists and other services.
» City officials in Downey approved the sale of land owned by Downey regional Medical Center to piH Health for $9.85 million. The Downey city council approved the sale as part of a plan that will merge 99-bed Downey regional with 548-bed PIH Health. under terms of the agreement, Whittier-based PIH Health must keep Downey regional open until at least 2030 and use the hospital site for only hospital or medical-related services until 2063. The merger between the two hospitals is still subject to approval by the state attorney general.
» The emergency department at Children’s Hospital Los Angeles was selected to receive the Lantern Award for outstanding patient service. The hos-pital was one of eight hospitals in the united States to receive the award from
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paramedics should undergo additional training that would allow them to make decisions in the field and potentially divert a large percentage of patients who don’t need emergency care to other facilities.
“Expanding the role of paramedics is a very promising model of community-based care that uses existing healthcare workers in new and innovative ways,” said Ken Kizer, director of the IPHI and a professor of emergency medicine at uC Davis. “It’s a model of care that several other states have implemented to bet-ter leverage the skills of paramedics to help ensure that emergency departments are more appropriately utilized.”
Kizer said pilot programs could give paramedics the opportunity to make decisions when they arrive at a call, such as releasing a patient on the scene who does not require emergency care or taking them to another facility such as a mental health crisis center. The report notes that the state Emergency Medical Services Authority (EMSA), which funded the report along with the California HealthCare Foundation, estimates that about one-third of 9-1-1 medical emer-gency calls are not true medical emergencies.
The report notes that paramedics in several states, including California, have been given a larger role in providing care through pilot programs. As part of a program in North Carolina, paramedics were given the authority to “treat and release” patients at the scene of an incident or refer them to another facility rather than transport them to the emergency department.
Another program developed by the city of San Francisco identified a group of about 225 “chronic inebriates” who frequently contacted 9-1-1 for emergency care. rather than wait for the core group of frequent callers to continue abusing the system, paramedics formed a Homeless outreach and Medical Emergency department to reach out to chronic inebriates and refer them to substance abuse or mental health programs.
The EMSA plans to launch “one pilot program with multiple project sites throughout California” in the summer of 2014 that involves “paramedics work-ing in an expanded role in their community.” The EMSA sent a letter-of-intent to providers requesting pilot program proposals in seven different areas, including a treat and release pilot.
“The deadline is Sept. 30 and we expect to receive 10 to 12 proposals,” said Jennifer Lim, EMSA deputy director of policy, legislative and external affairs.
Kizer said the arrival of federal healthcare reform should give providers ample incentive to test new ways of expanding the role of paramedics. “There are not enough healthcare workers in California already, especially in rural and medi-cally underserved areas, and the situation is likely to get worse in the next few years as a result of the Affordable Care Act expanding healthcare coverage to many previously uninsured people,” said Kizer. —Doug DesjarDins
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the Emergency Nurses Association and the only hospital in California. “This is a well-deserved acknowledgement of the emergency department team,” said Susan Cline, rN, the department’s education manager. “We care for the sickest and most critically injured chil-dren, adolescents, and young adults in our community. our lantern application demonstrated the strength of our nurs-ing professionalism.”
» Valley presbyterian Hospital is teaming with the Los Angeles Jewish Home for a Care transitions program for Medicare patients. The program will focus on more coordinated care of elderly patients after they’re dis-charged from Valley Presbyterian to their homes or other facilities. The pro-gram will employ “transition coaches” who will hold bedside meetings with patients before they are discharged and follow up with them at their homes within 48 hours of their discharge. The coaches will also help patients follow their post-care regimes and schedule follow-up appointments with physicians in an effort to prevent avoidable hospi-tal readmissions. “Helping our patients make a smooth transition from Valley Presbyterian Hospital to other health-care settings dovetails with our mis-sion of improving the quality of health in the San Fernando Valley,” said Julie reback, vice president of business development for Valley Presbyterian. officials at the 350-bed hospital based in Van Nuys expect the program to serve up to 1,300 Medicare patients each year.
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Dual-Eligible transition plan postponed Until April 2014pilot will transition 456,000 members to managed careState health officials have delayed the launch of a program to transition 456,000 dual Medicare-Medicaid patients from January 2014 until April 2014 at the earliest.
State health officials said they need more time to work with health plans and other partners to prepare for what could be a complex transition plan. “We want to assure readiness,” said Norman Williams, a spokesman for the state Department of Health Care Services (DHCS). “These are some of our most vul-nerable beneficiaries and many of them require care from several different types of providers.”
The state received federal approval in March for a demonstration program dubbed Cal MediConnect that will transition the state’s 1.2 million dual eligible beneficiaries to managed care. The first phase of the program was originally due to launch in June 2013 with 560,000 patients living in Alameda, Los Angeles, orange, riverside, San Bernardino, San Diego, San Mateo, and Santa Clara counties. The date was later pushed forward to January 2014 and the number of members scaled back to 456,000.
The DHCS said the program is designed to move patients out of a “fragment-ed system of care” into a program that provides “more coordinated care that helps prevent patients from falling through the cracks.” DHCS director toby Douglas said the transition “requires work on multiple levels between governments, health plans, and communities. This kind of systematic change takes time.”
Coordinating care for dual-eligible patients could generate considerable cost savings, because they tend to be heavy users of the healthcare system. A 2008 report from Health Affairs estimates that dual-eligible patients represent only 15% of the Medicaid population but generate 39% of total spending. The report also estimates dual-eligible patients represent 20% of all Medicare patients but generate 31% of total spending.
The California Medical Association (CMA) has expressed concern about the size of the pilot project and urged DHCS to “develop a scaled-down project that gives seniors and the professionals who take care of them information and feedback mechanisms to assure continuity of care and improved care coordina-tion.” CMA officials said that, during the transition of Seniors and persons with Disabilities to Medi-Cal managed care, some patients lost access to physicians they had been seeing for decades.
In response, DHCS said it’s working with the UC Davis Health System to develop a plan to monitor the dual-eligible transition program to ensure that members retain the level of care they need. —Doug DesjarDins
PAgE 4 of 14August 26, 2013
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Sept. 8-10. HFMA San Diego-imperial Chapters Fall Conference. long Beach Hyatt. A three-day educational confer-ence with a focus on accountable care initiatives and other programs to reduce healthcare costs and improve patient outcomes. Sponsored by the Healthcare Financial Management Association. To register, visit: http://www.hfma-cafall-conf.org/
Sept. 17. inland Empire Disabilities Collaborative: Aging Well with a Disability. San Bernardino Hilton. A free, one-day conference for healthcare professionals serving seniors and people with disabilities. Sponsored by the Inland Empire Health Plan. To register, please visit, http://www.iedisabilitiescollabora-tive.org/events_01.htm
Sept. 24. 12th Annual pay for performance Stakeholders Meeting. Marriott Burbank Airport. An annual gathering of pay-for-performance par-ticipants with a focus on new trends, new technologies, and best practices. Sponsored by the Integrated Healthcare Association. To register, please visit, http://www.iha.org/conferences_events.html
oct. 15. 2013 HASC Conference on Aging. Crowne plaza Hotel orange County. A one-day conference for health-care professionals that will exam new programs and strategies for promoting a healthier senior population. Sponsored by the Hospital Association of Southern California. To register, please visit http://www.hasc.org/AgingWell2013
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» A new California Field poll found that 50% of state residents are paying more for healthcare now than they were a year ago and that their healthcare costs are somewhat or very difficult to afford. The poll also found that 41% of state residents surveyed are paying about the same for healthcare this year and that 5% are paying less. The poll sponsored by the California Wellness Foundation also found that 53% of residents surveyed support federal healthcare reform with 38% opposed. of those respondents, 46% said they don’t expect to be impacted at all by healthcare reform while 23% expect to fare better and 26% expect things to be worse.
» Community Hospital of San Bernardino received a $200,000 grant from the San Manuel Band of Mission indians to purchase a state-of-the-art diagnostic tool for gastrointestinal problems. The grant was used to purchase a SpyGlass Direct Visualization System, which allows physicians to optically scan the gastrointestinal tract and receive live images to help identify obstructions and other problems. “San Manuel is a generous supporter of Community Hospital,” said June Collison, presi-dent of Community Hospital of San Bernardino. “We deeply appreciate their invest-ment in our efforts to continue to provide an exceptional standard of care.”
» A new report concluded that the state needs to step up efforts to monitor and track funding for mental health programs generated through proposition 63 and the Mental Health Services Act (MHSA). According to a report in the Sacramento Bee, California State Auditor Elaine Howle concluded that the state provides little oversight of MHSA funds allocated to counties to finance mental healthcare pro-grams. The audit was launched after a 2012 story from the Associated Press found that MHSA funds were being spent on programs that involved yoga, art classes, and horseback riding. “Media reports have expressed skepticism about county innova-tion programs, some of which include acupuncture and yoga,” the report stated. “Assessing and reporting on program effectiveness is therefore critical to ensure that only effective programs are continued and that the taxpayers and the public are assured that MHSA funds are put to best use.” The MHSA was created by the passage of Proposition 63 in 2004 and generates funds through a 1% income tax on state residents with annual incomes of $1 million or more.
» State health officials last week temporarily suspended Medi-Cal payments to eight additional drug and alcohol rehabilitation centers as part of an ongoing investigation into allegations of fraud in the state’s Drug Medi-Cal program. The eight additional clinics brought the total number of facilities that have had funding suspended to 116. The investigation of more than 1,000 substance abuse treatment clinics in the state that receive Medi-Cal funding was launched in July by the state Department of Health Care Services (DHCS) in response to reports of billing irreg-ularities that include clinics allegedly billing for non-existent patients and treating patients who do not have drug or alcohol problems. The DHCS is working with the federal Department of Justice on the investigation.
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Hospitalist(Los angeles, Ca/ San Jose, Ca/ Richmond, Va/ Las Vegas, NV/ Tucson,
aZ/ Cleveland, OH/ Cincinnati, OH)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 patients in the afternoon (usually 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 hospital are seen by the Hospitalists in the clinic until they are stabilized. 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 experience 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.
nurse practitioner(Los angeles, Ca/ Downey, Ca/ San Jose, Ca/ Modesto, Ca)
CareMore’s Nurse practitioners are the lead care managers for patients with chronic conditions. They provide exceptional care to our mem-bers in our Care Centers, and other care environments. education and/or experience: Master’s Degree in Nursing required. 2-5 years clinical background in Medical ICU or CCU as an RN or Np highly pre-ferred. Bilingual Spanish highly preferred, but not 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/ Los angeles, Ca/ San Jose, Ca)
The Nurse practitioner for our “Touch” program (institutional special needs plan), ensures effective and efficient treatment of our Touch mem-bers. 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 individual provides general medi-cal care and treatment to members in institutionalized settings such as nursing homes, assisted livings, or board & care facilities, under the direc-tion of the physician. education and/or experience: Master’s 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 the state in which you are applying.
careMore Manager regional clinical operations(Cerritos, Ca)
Responsible for overseeing the care center operations in counties of California and Nevada regions including new center development and start ups. primary duties may include, but are not limited to: Develops and implements business plans to ensure care center offices operate effi-ciently. Monitors quality measures. provides leadership to and oversight of clinical operations staff. Monitors compliance, implements corrective actions, and provides training on processes, procedures and workflows. assists with policy and procedure revisions and the development and implementation of new policies and procedures. partners with manage-ment to develop short and long-range business plans, objectives, strate-gies, and goals. Supports the clinical operations team in the development and establishment of care centers in expansion markets. Develops and implements protocols, policies, and procedures directly associated with Care Center operations. Implements and oversees operational structure in all new care centers. Hires, trains, coaches, counsels, and evaluates performance of direct reports. education and/or experience: Ba/BS degree preferred. 5 years of experience in the management of a large medical practice with multiple locations, including experience in an out-patient healthcare setting; or any combination of education and experi-ence, which would provide an equivalent background. experience with an electronic medical records (eMR) system required - Next gen experi-ence is a plus. Strong Microsoft Office skills. Must be flexible to travel nationally - 25% of job requires travel. Strong experience in quality measures monitoring and audit tool development. Certificates, Licenses, Registrations: Medical assistant Certification as required. LpN or LVN license preferred.
careMore Mgr i & ii care center(Los angeles, Ca/Tucson, aZ/Richmond, Va/Las Vegas, NV)
Responsible for providing supervision and leadership to the administra-tive and non-physician clinical staff of a small care center (typically less than 5 direct reports). Regularly performs the responsibilities of a medical assistant and at times perform these Ma responsibilities more than 50% of the day. primary duties may include, but are not limited to: Implements and monitors operational/office policy and procedures. ensures office processes are efficient and support the care center prac-tice and enhance patient satisfaction and retention. analyzes daily office operations and utilization of resources. Maintains appropriate staffing levels and morale. Interacts with regional manager to facilitate office operations to meet company objectives. Conducts monthly staff meet-ings. performs responsibilities of a medical assistant. Hires, trains, coach-es, counsels, and evaluates performance of direct reports. education and/or experience: Requires a high school diploma; 3 years of experience in a physician office including working knowledge of managed care and Fee-For-Service reimbursement requirements. Must have experience working with Medicare and Medicaid (duals) population. Knowledge in Medicare and Medicaid benefits and resources. 5 years’ experi-ence working in a multiple doctor clinic that does internal medicine. Certificates, Licenses, Registrations: Medical assistant Certification as required. LpN or LVN license preferred.
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uM Manager careMore utilization MgMt(Cerritos, Ca)
Responsible for the daily management of the CareMore utilization man-agement (UM) team. primary duties may include, but are not limited to: Supervises workflow and management of associates. assists in coordina-tion and development of UM quality initiatives. ensures compliance with departmental policies and procedures. Works in conjunction with other UM staff to improve service quality initiatives, develop audit tools, and meet National Management Information System (NMIS) and other qual-ity standards. provides quality control services such as call monitoring. Develops and implements associate training. performs audits to monitor efficiency and compliance with policies. prepares reports. Hires, trains, coaches, counsels, and evaluates performance of direct reports.Requires a high school diploma or equivalent; 2 years of operational experience; or any combination of education and experience, which would provide an equivalent background. Bi-lingual (english/Spanish) preferred.
provider network Manager i(Richmond, Va)
Develops the provider network through contract negotiations, relation-ship development, and servicing. primary focus of this role is contracting and negotiating contract terms. Typically works with less complex pro-viders which may include, but are not limited to, professional providers, practice groups, small medical groups, providers in less competitive mar-kets, and providers with greater familiarity with managed care concepts. Contracts tend to be more standard and afford less opportunity for customization. Fee schedules are fairly standardized with reimbursement models limited and well-defined. May participate in intradepartmental projects or smaller projects impacting multiple departments. Operates with general supervision, elevating unusual situations to management as required. primary duties may include, but are not limited to: Solicits par-ticipation in the network and conducts re-contracting efforts as needed. Serves as a communication link between professional providers and the company. Conducts limited negotiations and drafts documents. assists in preparing financial projections as required
Requires a Ba/BS degree; 2 years experience in contracting, provider relations, provider servicing; or any combination of education and expe-rience, which would provide an equivalent background. experience in managed care; preferred. ability to interface with geriatric population. Requires local travel up to 50%.
To submit your CV/Resume for consideration: Visit http://www.caremore.com/en/About/Careers.aspx to apply online. For more information about CareMore please visit www.caremore.com
Wilshire Health & Community Services, Inc. owns & operates Wilshire Home Health & Wilshire Hospice. We are currently seeking a Clinical Supervisor for our San Luis Obispo location.
clinical supervisorUnder the direction of the Director of patient Care Services, the Clinical Supervisor monitors/assures, supervises and directs field staff activities; is responsible for field staff competencies, and their safe and efficient comprehensive end of life care delivery to patients. The Clinical Supervisor is responsible for nurses, aides, social workers, spiritual counselors, hospice musicians and dieticians. additionally they super-vise the work of contracted personnel such as therapists.
• graduation from an approved school of professional nursing.• Current licensure by the state of California as a registered nurse with
at least 2 years experience in home health/hospice or community health within the last 5 years.
• Demonstrated knowledge of and ability to apply advanced principles of nursing care.
• Demonstrated leadership ability, teaching skills, and the capability to work effective with all levels of personnel.
Take a look at our website for more information: www.wilshirehcs.org.please e-mail resumes to [email protected].
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The goal of the Vp of Sales is to establish strong business relationships with health plans, self–insured employers, health care coalitions, and health care/pharmacy consultants. Vp of sales will work in assigned region and promote NCH’s full range of oncology and cardiology management and risk services.duties:
• Identify prospects in the assigned region and secure meetings with key decision makers—including CMO, Vp pharmacy, and CFO.
• Develop and maintain an “up to date” database of all prospects and contacts.• Secure news sales in accordance with assigned annual goals.• Manage contracting process with senior level management staff.
requirements: • Bachelor’s degree in Business administration and a proven documented sales
track record selling to large managed care organizations.• ability to demonstrate documented contacts in the managed care industry.• Knowledge of oncology and cardiology, DM, pBM or deep understanding
of managed care.• Impressive communication and presentation skills.• Understanding of how to manage a long term sale cycle.• C suite sales experience with a proven and documented track record.• Successfully able to foster a vision and gain commitment from stakeholders.• Demonstrated ability to work and integrate across functional lines.• extensive contacting experience.
contact: Rochelle Simkins, Human Resources Recruiting [email protected] or (714) 988-8609
www.newcenturyhealth.com
vice president, sales
Medicare coMpliance advisor
Reporting to the Compliance Officer, the Medicare Compliance advisor is responsible for ensuring that L.a. Care and its subcontracted provider network is compliant with all Centers for Medicare & Medicaid federal regulatory requirements. This position sup-ports L.a. Care’s Medicare compliance program by participating in annual ppg and quarterly audits, working with internal/external staff to correct perfor-mance deficiencies, identifying areas for improvement, representing L.a. Care with plan partners for member grievance oversight, provider services oversight, and interpreting CMS/SNp program requirements for L.a. Care. additionally, this individual is a resource to internal staff on compliance matters relating to CMS/SNp standards including, but not limited to, marketing materials, grievances and appeals, member right issues, and claims adjudication. Individual is also responsible for performing internal audits and moni-toring implementation of corrective measures.
Qualifications: The ideal candidate will possess a Bachelor’s degree in Business administration, public Health, or Healthcare administration, or five years of relevant experience. Candidate must possess a strong understanding of federal and state laws and regula-tory requirements. This position requires a minimum of four years in a managed care setting with at least one year working in Medicare managed care products. Must have strong attention to detail and be able to effectively manage multiple projects and priorities to meet deadlines; have highly developed analytical skills; have excellent oral and written communication skills; and have demonstrated experience developing and delivering training programs and making presentations to staff and health care providers.
preferred: Master ’s degree in Business administration, public Health, or Healthcare administration.
Qualified candidates please send resumes to [email protected].
director, revenue ManageMent
provide contract modeling and data/analytics support to the Senior Managed Care and Field Operations Team. aide in government and commercial contracting for Multiple Surgical Hospitals and aSCs. Responsible for modeling hospital and aSC contract pro-posals to gauge contract value while working effectively with the Reimbursement Team throughout the negotiation process. Will perform various reimbursement analyses to identify opportunities to highlight underpayment/denial issues and proactively pursue revenue optimization strategies. effectively and frequently com-municate goals, progress, and results to Sr. Director of Managed Care and Vice president(s) of Operations. position requires ability to work with large amounts of data utilizing various software systems as well as the understanding of the hospital, surgical hospital and ambulatory surgery center environment, particularly around various commercial and government reimbursement methodologies, insur-ance contracts, and payor systems. ability to interpret contract reimbursement’s impact on claims and utilization data and translate interpretation into action plans.
education/experience: Bachelor’s degree, 5+ year’s payor contract-ing/reimbursement experience in healthcare industry. Hospital and/or aSC operations experience a plus.
For consideration, please submit your resume to [email protected].
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director of claiMs & Medicare risk adJustMentThe Director of Claims & Medicare Risk adjustment is responsible for processing claims (operation, adjudication, and payment), producing relevant reports, and monitoring claims customer service; performs audits and reconciliations of claim charges, revenue and settlements; identifies billing, collecting carve-out benefits and insured services from the health plans; provides strategic leadership and con-sultation for the organization and contracted providers regarding Medicare Risk adjustment and the Five Star program; and directs a team of coders and adminis-trative staff in data mining and analysis. Ideal candidate will have a minimum of a Bachelor’s Degree, three (3) years management experience, three (3) years quality imp./project management experience and three (3) years of hands on experience in a HMO or Ipa environment with Claims/Risk adjustment Coding.
contract ManagerThe Contract Manager is responsible for the contracting functions and nego-tiation of selected Managed Care contracts and letters of agreement with HMOs, ppOs, Medical groups and state agencies within a particular regional area; reports contract performance and the maintenance of contract records/files; sets up procedures for assures that department managers are apprised of the status of negotiations and the impact of such contracts on their depart-ment operations; is the focal point for questions and education on Managed Care contracting issues; and will be assigned a supportive role on one or more of the major payer negotiations teams and will act as a knowledge resource for that major payer relationship. Ideal candidate will have a Bachelor’s Degree in Business administration, Healthcare Management, Organizational Development or related field is preferred, a minimum of three (3) years of current experience with healthcare contracting within a managed care organization, Ipa, or HMO. Two (2) years of management experience along with a working knowledge of medical terminology, claims payment, contract negotiations, and problem resolution; and ability to work collaboratively in a team setting.
sr. Medical directorSr. Medical Director will report to the Chief Medical Officer of the IDS and is responsible for the oversight of functions related to the quality of care delivered at pIH Health. This medical leader will oversee the medical operations for the enterprise and have about 20 director reports composed of Medical Directors and Department Chairs have responsibility over approximately 150 group physicians and 200+ Ipa physicians. The key responsibilities for this role are leading the pro-vision of high quality patient care, co-accountability for performance outcomes, developing and implementation of best clinical practice models, quality improve-ment, optimizing the eMR, and collaborating with key pIH leaders to ensure continuity of quality care between the inpatient and outpatient care setting. Ideal
With so many changes coming as a result of Healthcare Reform, ACO’s, and HCAHPS regulations, now is the perfect time to consider a career in the growing Ambulatory Care setting. Come join PIH Health Physicians and be a healthcare leader at the forefront of this change, and start enhancing your leadership expertise with an Integrated Delivery System (IDS) known for its warm, open and career advancing culture. PIH Health is a 550-plus bed acute care, nonprofit hospital that was founded in 1959 and today serves nearly 1.5 million residents in Los Angeles, the greater San Gabriel Valley and Orange County areas. PIH Health Physicians is comprised of a nonprofit medical foundation and a large independent physician association (IPA), related to PIH Health, which has over 150 primary care and 180 specialty care physicians. The medical foundation includes 17 medical office locations.
candidate will be an M.D. graduate from accredited medical school and comple-tion of residency in appropriate specialty and have a minimum of five (5) years clinical practice experience with prior medical administrative experience. We strongly prefer lean six sigma certification and either an MHa or other advanced health or business degree.
utilization ManageMent, Medical directorUtilization Management Director reports to the Chief Medical Officer of pIH Health, and will work in partnership with Department Chairs, Medical Directors and the administrative leadership at pIH Health. UM, Medical Director is respon-sible for the Medical Management functions that include Referral Management, Case Management, and Disease Management programs, as regulatory agen-cies require and the group and Ipa’s health plan contract stipulate. Medical Director shall work collaboratively with the pMg Departments to achieve the strategic goals of the department and pIH Health. This individual will have overall responsibility for ensuring that services and programs provided through the IDS are customer focused, clinically excellent, operationally efficient, and achieve effective patient outcomes. Ideal candidate will be an M.D. graduate from accredited medical school, Valid, unrestricted license to practice medicine in the State of California and have a minimum of five (5) years UM and/or Care Management experience within an Ipa/Medical group or health plan environ-ment. also, advanced knowledge of regulatory standards, particularly those relat-ing to The Joint Commission (TJC), CMS, HFCa, NCQa, and Hospital Conditions of participation for patients; Rights, and others as appropriate with a minimum of ten (10) years clinical experience, preferably in an academic ambulatory care environment. We strongly prefer lean six sigma certification and either an MHa or other advanced health or business degree.
Beyond the benefits that come with working for the area’s leading community healthcare provider–one that also recognizes the need to ensure patient safety and comfort–you’ll enjoy an extremely competitive compensation and benefits package including a work life balance program dedicated to keeping our profes-sionals as healthy and happy as possible. Our unique work life balance program includes free annual gym pass, annual balance checkup, financial roadmaps and social gatherings to get to know your office.
Our community is a great place to raise a family with an excellent selection of schools, an average of 310 days of sunshine per year and a 30 minute drive to the beach.
Now is the time to join this elite group. Recognized by Capg Standard of excellence as one of 36 physician groups in the state for its contributions to improving healthcare!
we are growing and seeking innovative leaders to Join our teaM
To apply or to find out more about this position, please visit www.pih.net or contact our recruiter at [email protected].
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page 10 of 14 august 26, 2013
director, Medicare stars prograM Medicare Committed to the promotion of accessible, high quality health care, L.a. Care Health plan (Local Initiative Health authority of Los angeles County) is an independent local public agency created by the State of California to provide health coverage to low-income Los angeles County residents. With more than one million members in five product lines, L.a. Care is the nation’s largest public health plan.
The Director, Medicare Stars program is responsible for driving and implementing strategy, providing guidance and serving as champion of Medicare Stars program across this organization’s Medicare Dual eligible Special Needs plan (D-SNp) line of business.
This position will use the candidates’ ability to develop and lead strategies to achieve improved quality ratings under the Stars program. The position will interface with other functional/operational areas to lead initiatives and build processes to achieve positive outcomes. This position affords the opportunity to become a pivotal leader, be innovative and strategic and build a robust and successful Stars program.
The ideal candidates will possess a Bachelors degree or equivalent experience, 5-7 years clinical or Medicare managed care plan experience; and at least 2 years supervisory or management experience required.
Interested candidates please send resumes to [email protected].
director, provider services Responsible for the strategic direction and management of activities and staff associated with the provider Services Unit including developing and overseeing department planning, staffing, training, resources, workflows, network development, provider communication, education, problem resolution & partnership development. Requirements: Bachelor’s degree, or equivalent plus three years in a health care/managed care environment required. Three years man-agement experience. Must have strong interpersonal, problem solving skills & ability to lead, motivate & supervise. Must be able to establish forward-looking goals and delivers results.
senior director, case ManageMent and ltss servicesResponsible to develop, implement and monitor the intake, assessment, care coordination and case management processes including execution and development of unit, administration of budget, hiring and staff man-agement, strategic direction and daily operations of processes to ensure members care coordination and case management services.Requirements: Bachelor’s Degree in nursing, business management or related field. Minimum five years in care coordination/case management in health care and community-based setting.
EEO. We offer excellent salary and benefits. For details and to apply,
please visit www.alamedaalliance.org
Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help
people be healthy, secure and comfortable. Health Net, through its subsidiaries, provides and administers health benefits to approximate-ly 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as “part D”), Medicaid, U.S. Department of Defense, includ-ing TRICaRe, and Veterans affairs programs. Health Net’s behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance pro-grams to approximately 4.9 million individuals, including Health Net’s own health plan members. Health Net’s subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.
For more information on Health Net, Inc., please visit the company’s website at www.healthnet.com.
Medical director, central Medical ManageMent
Woodland Hills, Ca
JoB suMMarY: • The Medical Director, Central Medical Management, works to
actively ensure that centralized medical management activities result in cost effective, quality-oriented health care consistent with the member’s health care benefit package and designed to provide the member the best possible clinical outcomes. Centralized medical management activities consist of such functions as prior authorization, appeals and grievances, case management, and retrospective review.
education: • graduate of an accredited medical school; Doctorate degree in
medicine or osteopathy
certification/license: • Board certification in an aBMS recognized specialty• Unrestricted California Medical License
experience:• Minimum five years medical practice after completing residency-train-
ing requirements for board eligibility• Minimum three years medical management experience in a
managed care environment• experience with Medi-Cal program and /or Medic-Cal patients pre-
ferred
We offer a competitive salary, an attractive incentive plan and com-prehensive benefits. Health Net, Inc. supports a drug-free environ-ment and requires pre-employment background and drug screening. Health Net and its subsidiaries are an equal Opportunity/affirmative action employer M/F/V/D.
To view the full description of this position and/or to apply please visit us at www.careersathealthnet.com and view
requisition 13001321.
to place a listing, please call 888-834-4678
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page 11 of 14 august 26, 2013
director of contractingas a director of contracting you will lead and manage the development of Humana’s overall provider relationships within the Ca market. You will drive strategic initiatives within the provider network and ensure that the alignment of departmen-tal objectives is congruent with the overall business strategy.
Hospital contractoras a Hospital contractor you will strategically engage the Ca hospital provider community and negotiate contracts that are favorable to Humana’s business, opening doors for Humana’s continuing penetration of the marketplace, and ensuring that our networks are competitive within the industry.
Humana is seeking a director of contracting and a Hospital contractor in Torrance, Ca
If you’d like to be part of the national contracting team at Humana where you will help build and maintain a competitive network for our members, and provide a comprehensive hospital network to consumers, you may be interested in these career opportunities.
apply If you have network contracting experience and would like to join our team, visit Humana careers and review requisitions 105174; 109036 or 109037 for qualifications and assignment details. Or send your resume to Joanne Kane at [email protected].
Humana careers can change lives—including yours. as an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
apply now, or join our talent network so you can stay informed and up to date on what’s happening at Humana.
new century Health is a leading innovator of specialty care management programs for oncology and cardiology. We are
currently seeking candidates for the following career opportunities:
3 Vice President, sales – (telecommute)
3 network oPerations rePresentatiVe – miramar, Fl
3 data integration deVeloPer – Brea, ca
3 Microsoft dynaMics crM PrograMMer – Brea, ca
3 Peer reViewer – Md – Brea, ca
3 intake coordinator (Pharmacy tech) – Brea, ca
3 Project Manager – Brea, ca
3 data configuration analyst – Brea, ca
3 claiMs exaMiner (ccS or ccS-P) – Brea, ca
3 utilization reView rn (oncology) – Brea, ca
3 utilization reView rn (cardiology) – miramar, Fl
Please submit resumes to [email protected]
www.newcenturyhealth.com/Careers.html
Gold Coast Health Plan currently has the following positions available:
chief Medical officerdecision support services Manager
director of Health servicesHealth services informatics specialist
compliance specialist- delegation oversighti.t. Business systems analyst
Human resources generalist- recruitingMember services data analyst
Qi- facility site review rnsenior policy analyst
sr. provider claims analystMember services representative i
For more information, please visit our website at: www.goldcoasthealthplan.org/about-us/careers.aspx
Contact: Stacy Diaz, Human Resources [email protected]
to place a listing, please call 888-834-4678
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page 12 of 14 august 26, 2013
supervisor, pHarMacY tecHnical operations Requisition # 13-1107
Hcc tools specialist Requisition # 13-1128
QualitY/5 star initiative developer Requisition # 13-1057
financial analYst – coMMissions & incentives Requisition # 13-1138
internal it auditor Requisition # 13-1165
Manager Hcc Requisition # 13-1096
director network ManageMent adMinistration Requisition # 13-1171
clinical review Manager Requisition # 13-1172
SalES IntEgrIty aSSESSOrS Requisition # 13-1213, # 13-1211, #13-1210 and #13-1208
For more information, please visit our website at: www.scanhealthplan.com/about-scan/resources/job-postings
New Century Health is a leading innovator of specialty care management programs for oncology and cardiology.
Managed care attorneY and coMpliance advisorThe position focuses on providing counsel on contracting and regulatory matters. The successful candidate will be responsible for understanding and interpreting utilization review and health insurance laws and regulations. Other responsibilities include drafting and reviewing company policies and proce-dures, and preparation and negotiation of contracts and other legal documents. provide guidance to product and service related issues, including interpretations of state and federal laws applicable to the health care industry/managed care services. Create and implement contract templates and processes. Negotiate and prepare provider network participation agreements.
Qualifications• 3-5 five years’ health insurance legal and regulatory experience, or similar• Juris Doctor from ABA accredited law school• Active membership in a state bar association• Strong legal writing, research and analytical skills• Ability to work collaboratively and under general supervision of senior legal and
compliance resources
contact: Rochelle Simkins, Human Resources Recruiting [email protected] or (714) 988-8609
www.newcenturyhealth.com
description of position
Financial analyst will work with Director of Finance and CFO to prepare wRVU calcula-tions for providers in the California Region, monthly volume analysis, monthly practice financials and monthly operations reports. Will work under the direction of the Director of Finance to develop additional reports to facilitate month end close process and develop and populate dashboards. Financial analyst will assist with the development of annual bud-gets and quarterly forecasts. Financial analyst will extract and compile data from various systems to develop sound analyses to support month end close. To be successful the finan-cial analyst needs a working knowledge of wRVU’s, Medicare/Medicaid reimbursement rules for physicians and the ability to read and interpret contracts.
required knowledge and experience:
• Undergraduate degree in accounting or finance or equivalent experience1-2 years financial analysis experience, healthcare management, preferably physician practices
• High level of analytical skills and extensive knowledge and proficiency with Microsoft excel and Word
• Capacity to review, identify and implement improvement opportunities where new processes, technologies or efficiencies can be applied.
• Comprehensive conceptual problem solving and analytical skills utilizing complex spreadsheets, comparison tools and other evaluation systems as needed.
• Strong investigational skills, attention to detail, accuracy and the ability to manage and prioritize multiple tasks.
• Independently organize work plan for assigned projects within team structure and develop constructive working relationships with others.
• Skilled in oral and written communication with a diverse level of participant knowledge and ability.
• Intermediate knowledge of financial modeling techniques
please forward resumes to: [email protected]
financial analYst
to place a listing, please call 888-834-4678
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page 13 of 14 august 26, 2013
vp of network ManageMent
Manager of network ManageMent
applecare Medical Management is committed to providing the highest level of service to our health plan members and physicians. We have been providing care to Los angeles and Orange County for over 15 years, making the health of our patients our first priority.
We currently seek a qualified candidate for the vp of network Management position. appleCare Medical Management seeks a qualified candidate to lead our Network Management department in Los angeles and Orange County. as part of the management leadership the position will lead the ongoing development of network management and provider relations.
requirements: a minimum of 7 years of experience in managed health care that includes extensive experience in network man-agement and provider relations. Must have solid working knowl-edge of contracting, finance, IT, and UM/case management.
For immediate consideration, please email/fax resume with salary requirements: [email protected] or Fax 714.443.4540.
We seek a qualified candidate for the newly created Manager of network Management position. Responsibilities: Manage functions relating to provider servicing, provider education and network development per Network territory. Manages provider Services Team, (provider Relations Reps, In-House Coordinator, other provider associates). Monitors team activities to meets performance standards; operates effectively and efficiently. produces Quickbase departmental metrics reports. Manages escalated claims/operational issues, assures timely resolution of provider issues.
requirements: Ba/BS Degree or equivalent experience. 5 years network management in a managed care environ-ment. Minimum one year leadership/management experience.
For immediate consideration, please email resume with salary requirements to [email protected].
appleCare offers a competitive benefits package including medical, dental, vision, 401(k), life and aD&D insurance, vacation and holiday pay. appleCare offers a supportive and positive work environment which encourages growth and success.
supervisor, Bpo claiMsResponsible for ensuring Business process Outsourcing (BpO) claims are processed, adjudicated in date order and by claim type within appropriate time frame. assist in daily staff supervision and claims paper flow including vendor relationship building and resolving complex claims.Requirements: Three years in medical or health care claim-processing environment preferably in Managed Care. One year minimum experience as a supervisor. Detailed knowl-edge of CpT, RVS, ICD-9, HCFa 1500, UB-92 coding and forms benefits.
Visit us at www.alamedaalliance.org. Click on Employment for specific job information
and to apply. EEO
director, provider contracting
Help deliver a high-quality health care experience to more than one million angelenos when you join L.a. Care Health plan, america’s largest public plan serving Los angeles County’s low-income and underserved communities. We’re seeking a dynamic individual for this highly-strategic position to work with L.a. Care’s physician and provider networks and ensure our members have the quality health care they deserve.
This individual must be able to develop, negotiate, and manage financially sound contracts and strategies with participating physician groups (ppgs), management service organizations (MSOs), hospitals, ancillary providers, and other health care providers. Thorough knowledge of DRg and Medicare reimbursement policies is critical for supporting L.a. Care’s participation in Cal MediConnect (Duals) among other initiatives of health care reform. additionally, staff management and training are key components of the position.
The ideal candidate will have at least 5 years of provider contracting and staff management experience; strong team leadership and presentation skills; and excellent understanding of the provider community and health care delivery systems. L.a. Care offers competitive salaries and an attractive benefits package.
To apply, go to http://www.lacare.org/employment/opportunities
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page 14 of 14 august 26, 2013
senior provider contracts specialist
L.a. Care, america’s largest publicly operated health plan, has exciting new employment opportunities in this time of great change in health care. We seek an outstanding individual with at least 5 years experience in complex provider contracting to help us serve our diverse membership in L.a. County. The ideal candidate will initiate, negotiate and finalize complex provider contracts, conduct f i r s t - l eve l f i nanc ia l mode l i ng , and w i l l l e a d a s u p p o r t t e a m d e d i c a t e d t o n e g o t i a t -ing and ana lyz ing managed care contracts with physicians. Must be analytical and detail oriented, able to manage multiple complex projects, and possess excellent oral and written communication skills. Individual will need a bachelor’s degree or a minimum of 5 years equivalent contractual experience in a health care setting. L.a. Care offers an excellent benefits package and a professional working environment.
To apply, go to http://www.lacare.org/employment/opportunities
coMpliance advisor
Reporting to the Manager, Delegated provider Oversight, the Compliance advisor is responsible for ensuring that L.a. Care and its delegated subcontracted provider net-work is compliant with all program contractual, state and federal regulatory requirements for all product lines (Medi-Cal, Medicare, Cal-MediConnect, Healthy Kids, IHSS). This position participates in the initial due diligence reviews and annual audits and working with subcontract-ing providers to correct performance deficiencies, serving as the Compliance contact assigned to subcontracting health plans, participating physician groups and hospitals. This position must be able to interpret Medi-Cal, Medicare and other product line program requirements for L.a. Care and its contracted entities.
QUalIFICatIOnS: The ideal candidate will possess a Bachelor’s degree in Business administration, public Health or Healthcare Management, or 5 years of equiva-lent experience. Candidate must be able to manage mul-tiple priorities and projects, meet deadlines, and have excellent written and oral skills for making presentations to internal staff and providers. Individual must have work-ing knowledge of DHCS, DMHC and CMS requirements, as well as highly developed analytical and critical thinking skills. Work experience in the administration of a health plan, physician group, or hospital is essential.
Preferred: Master’s degree in Business administration, public Health, or Healthcare administration.
Qualified candidates please send resumes to [email protected].
Manager of Marketing and Business developMent
Responsible for developing, implementing and managing strate-gies to ensure achievement of company growth. Responsible for overall marketing functions and activities which includes developing a marketing plan and programs to achieve increased market recognition. Responsible for physician recruitment including maintaining and strengthening existing relationships. Bachelor Degree, Marketing/Business Development, strong written & verbal communication skills are essential; healthcare marketing experience is strongly preferred.
Interested candidates should send their resumes in confidence to: [email protected]