Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Reporting directly to the Director of Payment Integrity (PI), and cross-accountable to the Senior Director of Operational Assurance, the Payment Integrity Regulatory and Contract Strategy Advisor II, either individually or collaboratively, researches, elicits, analyzes, communicates, tests, and verifies all requirements applicable to the Payment Integrity organization for all lines of business (Medicaid, Medicare, and Commercial). Documents the requirements and business decisions, their corresponding authority, and the status of compliance with said requirements in a comprehensive function-based index, stratified by sub-function level requirements for each product line, and will leverage the requirements to monitor and oversee all functions within this positions' purview. This role stays knowledgeable of regulatory and policy changes, as well as industry best practices, trends, and innovation through ongoing research, professional development, and peer contact specific to L.A. Care's ecosystem. The Advisor will also identify regulatory and contract requirements impacting Payment Integrity activities. This position will be indirectly responsible for the integration of all current and future contracts into edit logic for accurate execution. Additionally, this position will develop oversight and monitoring programs for delegated entities and L.A. Care's Plan Partners to ensure the timely prevention, detection, and remediation of waste and abuse, and to drive incremental savings across all L.A. Care's lines of business.
The Advisor will also examine, and as necessary, strengthen process integrity and controls to manage accountabilities, mitigate risks, and protect the Plan from process waste, enforcement actions, sanctions, and other adverse outcomes, in collaboration with key stakeholders. Supports the development of all initiatives and infrastructure in the Payment Integrity organization that are required to achieve L.A. Care's strategic objectives.Duties
Elicits, documents, analyzes, communicates, tests, verifies, and systematically tracks requirements for the Payment Integrity organization. Develops and implements an efficient method for readily identifying regulatory and contractual requirements across all lines of business that impact existing and future Payment Integrity activities. Reviews and approves contract language requirements for Payment Integrity updates. Identifies edit customizations based on contract requirements and forward identifications to Payment Integrity operations.
Implements new processes for review of all L.A. Care policies, state and Federal rules, regulations and/or requirements for the purpose of Oversight and Monitoring of PPGs and other Plan Partners Payment Integrity activities.
Manages the creation and execution of strategies that determine impact of opportunity and recover overpayments of each pipeline opportunity as it relates to PPGs and other Plan Partners.
Collaborates with the Manager, Payment Integrity Operations Development in developing and implementing prospective internal controls preventing future overpayments of each pipeline opportunity.
Provides subject matter expertise, recognizes, and analyzes gaps between current operations and desired outcomes utilizing appropriate resources to obtain information, consider and deliver solutions.
Supports Payment Integrity Leadership with implementations and algorithm/edit customizations by providing program/payment integrity (cost containment) experience and expertise as needed.
Performs other duties as assigned.Education Required Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Juris Doctor Degree or Doctor of Law Degree (J.D.) Experience
Minimum 5-7 years of experience in contract and/or regulatory and/or accreditation requirements analysis in managed care or other related health care industry; or, healthcare experience in external regulatory or governing entity audit preparation; or in Healthcare Compliance, or other Compliance-related field. Higher Education may be considered in lieu of requried years of experience.
Experience in contract, legal, or regulatory topics; a complex business setting, local, State, or Federal government entity, managed care, or other related industry.Skills
Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.
Strong project leadership skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.
Knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.
Excellent interpersonal, verbal, and written communication skills required.
Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.
Must be able to present findings to various levels of management, across all organizationsLicenses/Certifications Required Licenses/Certifications Preferred Certified Professional Coder (CPC) Required Training Additional Information
L.A. Care offers a wide range of benefits including
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
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