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June 1, 2015 | VOLUME 22 | NUMBER 22

T O P S T O R I E S

Covered California to Cap Out-of-Pocket Drug Costs in 2016Monthly limits address high-cost medications

Covered California approved new caps on prescription drugs that will establish monthly limits on out-of-pocket spending for health plan members starting in 2016.

The health exchange board of directors voted to approve the caps as part of an effort to rein in costs of some high-priced drugs for chronic conditions such as Hepatitis C and HIV. The out-of-pocket caps will range from $150 to $500 per month based on the type of health plan and will go into effect Jan. 1, 2016.

“This is the first time that an exchange has ensured that all of its consumers have access to the medications they need,” said Covered California executive direc-tor Peter Lee. “These new policies strike a balance between ensuring that Covered California consumers can afford the medications they need to treat chronic and life-threatening conditions while keeping premiums affordable for all.” Lee said the caps were designed with input from a wide range of stakeholders that included consumer advocacy groups.

The spending caps will vary based on the type of plan, which are tiered on the exchange in Platinum, Gold, Silver, and Bronze plans. People with Platinum and Gold Plans, the more expensive and higher-benefit plans, will have a monthly out-of-pocket cap of $250 per prescription and Silver Plan policyholders will have caps ranging from $150 to $250 depending on the type of plan. Bronze Plan members will have a monthly per-prescription cap of $500 per month. The out-of-pocket cap for total healthcare spending per year for Bronze individual plans is $6,500.

State insurance commissioner Dave Jones described the caps as a “partial victory” for consumers, noting that he and other consumer advocates were pushing for a $300 monthly cap on prescription drug spending for Bronze Plans, the lowest-priced plans on the exchange. “The $500 cap per prescription per month—in addition to the $500 pharmacy deductible for the Bronze Plan—makes prescription drug coverage unaffordable to Californians who buy Bronze Plans, one of the most popular health insurance levels of coverage,” said Jones.

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

Covered California cont. » The California Department of

Public Health (CDPH) fined 12 hospi-tals in the state a total of $775,000 for medical errors that included leaving a surgical scalp clip inside a patient following surgery and improper use of patient restraints. Receiving fines of $100,000 were Mercy Medical Center in Merced and Marin General Hospital in Greenbrae. Receiving fines of $75,000 were California Pacific Medical Center in San Francisco, Kaiser Foundation Hospital in San Diego, and Orange Coast Memorial Medical Center in Fountain Valley. Receiving fines of $50,000 were Community Hospital of the Monterey Peninsula, Desert Valley Hospital in Victorville, Glenn Medical Center in Willows , Redlands Community H o s p i t a l , S a n D i e g o C o u n ty Psychiatric Hospital, Scripps Medical Center in Chula Vista, and Seton Medical Center in Daly City. Hospitals must file a corrective action plan with the CDPH and can appeal the penalties.

» The California Medical Association (CMA) has dropped its opposition to Senate Bill 128, which would allow physicians to assist terminally ill patients to end their lives at the time of their choosing. The CMA changed its position on the End-of-Life Option Act from “oppose” to “neutral” and said end-of-life decisions should be left up to individual physicians and patients. “As physicians, we want to provide the best care possible for our patients,” said CMA president Luther F. Cobb, MD.

Though some groups were critical of the higher Bronze Plan caps, Covered California officials said the goal of the caps is to strike a balance between protecting consumers and keeping premiums down.

“With no caps in place, some people are forced to exhaust their annual out-of-pocket spending in just a few months,” said Covered California spokesman James Scullary. “The caps will limit the amount of money people have to spend each month and spread out the expense.” Scullary said the caps are expected to directly increase Covered California premiums by 1% in 2016 and between 0% and 3% per year over the next three years.

The California Chronic Care Coalition described the caps as “an historic step to help quality, access, and affordability of special medications” but also expressed concern about the $500 cap for Bronze Plan members.

“While the Covered California cap is an important first step to help meet the needs of vulnerable patient populations, more must be done to help ensure that all patients, particularly those with multiple chronic conditions, can afford treatment,” said California Chronic Care Coalition CEO Liz Helms. “We are hopeful that Covered California will re-examine price caps for Bronze plans and make adjustments in the near future.” —DOUG DESJARDINS

Western Dental to Scale Back Participation in Denti-CalDental provider cites low Medi-Cal reimbursement rates

The largest provider of dental services for Medi-Cal patients in California will stop accepting new patients at some locations starting this month due to low reimburse-ment rates for dentists.

Western Dental plans to stop accepting new patients at 13 locations effective June 1. Western Dental CEO Simon Castellanos could not be reached for comment but told the Orange County Register that “the concentration of Denti-Cal patients in our facilities is overwhelming.” Castellanos also said that reimbursement rates “have not increased since 2001” and that “given the situation with the Denti-Cal program, we’ve been forced to question our continued participation.”

Moody’s Investors Services downgraded Western Dental parent company Premier Dental Services in May, citing a decline in operating margins it attributed largely to Western Dental’s presence in Denti-Cal.

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“However, despite the remarkable medi-cal breakthroughs we’ve made and the world-class hospital or palliative care we can provide, it isn’t always enough. The decision to participate in the End-of-Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed [a] policy that outright objects to physi-cians aiding terminally ill patients in end-of-life options.” Sen. Lois Wolk, who co-authored SB 128 with Sen. Bill Monning, said that “we are pleased to learn that the medical community is making a historic shift from a previous position on this issue.”

» A study from the UCLA Center for Health Policy Research found the rate of uninsured children in the state declined from 13% in 2003 to 8.9% in 2012. The study that used 10 years of data from the annual California Health Interview Survey also found that 97% of young children in the state had a usual source of medical care in 2012. “These are really encouraging trends for the health and well-being of children,” said Sue Holtby, a program director with the Public Health Institute and lead author of the study. “But some beneficial services remain out of reach for low-income families and the chal-lenge for policymakers is to continue to improve access to—and quality of—the care children receive.” The study also found that the number of children cov-ered under private health plans declined from 57% in 2003 to 44% in 2012.

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“The declining operating margins are due primarily to the restoration and expansion of certain benefits for adult Denti-Cal coverage by the state of California in mid-2014,” the Moody’s report stated. “This has resulted in a significant payer mix shift due to the higher proportion of lower-margin patients covered by Denti-Cal. In addition, the higher frequency of Denti-Cal patient visits is also expected to continue to displace higher-paying, out-of-pocket or commercial insurance customers, result-ing in lower average reimbursement rates for the company’s services.”

The state Department of Health Care Services (DHCS) said it’s aware of Western Dental’s plan to scale back its participation in Denti-Cal. “The DHCS is very concerned about the potential impacts to Medi-Cal beneficiaries resulting from any service reductions by Western Dental,” said DHCS spokesman Tony Cava. “We remain committed to working to ensure that our Medi-Cal members have access to quality dental care…” The DHCS said Western Dental served more than 562,000 Medi-Cal patients in 2014, making it the largest Denti-Cal provider in the state.

Healthcare advocates say Western Dental’s decision to move away from Denti-Cal is not surprising, given that California has some of the lowest Medi-Cal reimbursement rates in the nation that make it difficult for dentists to take part in the program.

“That’s not because there are not enough dentists,” said Serena Clayton of the California School Based Health Alliance. “It’s because there aren’t enough dentists who can afford to see patients since the reimbursement rate for their den-tal services hasn’t been adjusted for inflation since 2001. In fact, it was cut in 2013 because of the state budget deficit.”

Cava said the state is currently working on a plan for improved dental reim-bursements for Medi-Cal as part of its Medicaid waiver renewal process. “We are taking steps intended to expand access, including reducing administrative burdens for dental providers, and have included proposals in our federal 1115 Medicaid waiver application that would specifically target funding for new providers who agree to dedicate part of their practice to Medi-Cal patients and to existing providers who expand the number of Medi-Cal patients they will see,” Cava said. The current Medicaid waiver program is due to be renewed in October.

A group of 16 California congressional leaders is looking for more immediate relief. The group headed by Congresswoman Loretta Sanchez (D-Garden Grove) sent a letter to Gov. Jerry Brown urging him to provide additional funding for Denti-Cal in the state’s fiscal 2016 budget due to go into effect in July. The letter cited a report from the California State Auditor that estimates Denti-Cal reimbursements for the 10 most common procedures in 2012 was $21.60, about 35% of the national average of $61.96. —DOUG DESJARDINS

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» Covered California has appointed Lance Lang, MD, as its new chief medi-cal officer. Lang will replace Jeffrey Rideout , MD , who left Covered California to become president and CEO of the Integrated Healthcare Association. “Dr. Lang is a great fit for us,” said Covered California execu-tive director Peter Lee. “He brings to Covered California tremendous skills that will help fulfill its role as an ‘active purchaser’ that negotiates with insur-ance carriers to ensure the best quality of care for our consumers at affordable rates.” Lang most recently served as a consultant with the California Quality Collaborative and previously held exec-utive positions at insurer Health Net and at Kaiser Permanente.

» Sutter Health announced a part-nership with Boehringer Ingelheim Pharmaceuticals for a program to improve care for patients with chron-ic lung disease. According to a report in the Sacramento Business Journal, the five-year program will test digital health programs and mobile devices as part of a larger effort to monitor the effectiveness of chronic lung disease treatments. In early May, Sutter Health signed a similar partnership with AstraZeneca to test new approaches to treating chronic health conditions such as diabetes and hypertension.

» Sharp HealthCare received a $5.7 million donation that will help estab-lish a brain cancer center. The dona-tion was made by the family of Laurel Amtower, a former professor at San

Senate Approves Expanded Scope of Practice Bill for Optometrists SB 622 would allow optometrists to administer vaccinations

The state Senate approved a bill that would expand the scope of practice for optometrists and allow them to perform minor eye surgeries and administer vac-cinations to adults. The California senate voted 34-4 to approve Senate Bill 622. The bill authored by Sen. Ed Hernandez (D-West Covina) will move next to the state Assembly for consideration. Hernandez said the bill will allow optometrists to pursue additional training and expand their scope of service into one area of primary care. “The Affordable Care Act has placed three million additional Californians into our healthcare system,” said Hernandez. “This bill will allow doctors of optometry to examine, diagnose, prevent, and treat conditions to the full extent of their training.” In order to be accredited for expanded services, optometrists will need to be certified and undergo “50 hours of post-doctoral education and training on human patients.” Optometrists who undergo training will be able to administer vaccinations to people aged 18 and older for influenza, herpes zoster, and pneu-monia. With proper training, optometrists will also be eligible to perform laser procedures to treat glaucoma and minor surgeries that entail removing small lesions from the surface of the eyelid. The California Optometric Association (COA) said SB 622 will allow optom-etrists to tap into the full potential of their training. “Doctors of optometry are an important part of the healthcare field,” said Barry Weissman, OD, president of the COA. “With the Affordable Care Act, the shortage of doctors continues to grow. Optometrists in California are highly trained healthcare professionals who already have obtained a doctorate degree from an accredited college of optometry.” If it is approved, SB 622 would be the second bill authored by Hernandez to expand the scope of service for healthcare providers. In 2013, state legislators approved Senate Bill 493, which expanded the scope of service for pharmacists. The bill, which goes into effect this year, will allow pharmacists to initiate pre-scriptions for contraception and provide patient consultations. Hernandez said the bill “will help ensure that millions of new patients receiving insurance will be able to access healthcare services through their local pharmacist.” Hernandez has promoted the concept of expanding the scope of service for healthcare providers to address a shortage of primary care physicians, particu-larly for Medi-Cal patients. A study from the California HealthCare Foundation found there are currently 35 to 49 primary care physicians per 100,000 Medi-Cal patients in the state, well below federal guidelines that recommend 60 to 80 physicians per 100,000 patients. —DOUG DESJARDINS

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June 7-10. California Health Information Association Convention & Exhibit. Palm Springs Convention Center. A four-day con-vention and exhibit focused on changes and emerging trends in healthcare infor-mation technology. To register, please visit http://www.californiahia.org/conven-tion-exhibit

June 11-12. HASC Health Care Provider Wellness Conference. Renaissance Long Beach Hotel. A two-day conference that will bring together experts in healthcare economics, clinical intervention, and com-munity leadership in a variety of healthcare settings. To register, please visit https://www.hasc.org/2015WellnessConference

June 11-15. 2015 CAPG Healthcare Conference. Grand Hyatt Hotel, San Diego. An educational conference for phy-sicians and medical group administrators. Sponsored by the California Association of Physician Groups. To register, please visit https://capg.cvent.com/events/2015-capg-healthcare-conference/custom-35-0f33f-32458014277b47afffa9aa78846.aspx

July 19-22. CAHF and QCHF Institute Summer Conference. Loews Omni La Costa, Carlsbad. An educational conference for healthcare profes-sionals sponsored by the California Association of Health Facilities and the Quality Care Health Foundation Institute. To register, please visit http://www.cahf.org/MeetingsEvents.aspx

Diego State University who died from brain cancer, and will establish the Laurel Amtower Cancer Institute and Center for Neuro-Oncology at Sharp Memorial Hospital in San Diego. “It is incredibly challenging to treat tumors in the central nervous system, so expediting care and tailoring it to each patient is crucial,” said Charles Redfern, MD, medical director for the cancer institute, which will launch this summer. Sharp HealthCare said the Laurel Amtower Cancer Institute will give patients access “to the latest technology to diagnose and treat tumors as well as cutting-edge clinical trials and research.”

» J. Brian Ternan has been named president of Anthem Blue Cross and will over-see the insurer’s commercial operations in California. “Brian is a unique talent and we’re thrilled to have him lead our California team,” said Pam Kehaly, president of Anthem’s West region. “As our industry transforms into one where consum-ers are making more purchasing decisions, Brian’s experience and market insights will be invaluable in leading our California efforts.” Ternan most recently served as Aetna’s western region president. Prior to that, he headed West Region sales for UnitedHealthcare. Ternan replaces Mark Morgan, who left Anthem in April. “It’s an honor to be asked to lead this team and I look forward to finding even better ways for Anthem to serve our 8.5 million California members,” said Ternan.

» Alameda Health System (AHS) has appointed Delvecchio S. Finley as its new CEO effective in August. Finley currently serves as CEO of Harbor-UCLA Medical Center, a position he has held since 2011. “Mr. Finley has exceptional experience well suited for the future of AHS as we move forward into a period of sustainabil-ity, growth, and investment in the organization,” said AHS board president Kirk Miller. Prior to joining Harbor-UCLA, Finley served as vice president of operations at California Pacific Medical Center and also held executive positions at San Francisco General Hospital. Finley will replace former CEO Wright Lassiter III, who left AHS last December to join the Henry Ford Health System. Since Lassiter’s departure, Daniel Boggan Jr. has been serving as interim CEO.

» Community Hospital of the Monterey Peninsula has agreed to join a coor-dinated care program administered by Anthem Blue Cross. The program targets patients with two or more chronic conditions and focuses on helping them man-age their conditions more effectively. “Community Hospital has been investing for years in resources to manage complex and chronic conditions across the continuum through its team at Community Health Innovations and we are glad to partner with Anthem to offer these resources to our community,” said Steven J. Packer, MD, president and CEO of 205-bed Community Hospital, which will join 19 other providers in the state taking part in the program.

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March 31, 2014 | VOLUME 30 | NUMBER 12

T O P S T O R I E S

Number of Physicians in State has

Increased 39% Since 1993

Many areas still have shortage of physicians

A new study from the California HealthCare Foundation (CHCF) shows the

number of physicians in California has increased 39% over the last two decades but

that not all regions of the state are benefiting from the increase.

The study titled California Physicians: Surplus or Scarcity? estimates that

the number of physicians in the state increased 39% from 66,151 in 1993 to 91,775

in 2011, a percentage that’s nearly double the state’s 20% increase in population

during that period. But despite that increase, the report shows many regions of the

state still have a shortage of physicians.

The federal government recommends that communities have between 60 and

80 primary care physicians for every 100,000 residents to ensure adequate access

to care and between 85 and 100 medical specialists for every 100,000 residents.

In 2011, California met that requirement statewide with 64 primary care physi-

cians for every 100,000 residents and exceeded it with 130 specialists for every

100,000 residents.

But the study showed sharp disparities in physician supply by region. The San

Francisco Bay Area had 86 primary care physicians and 175 specialists for every

100,000 residents in 2011, well above the state average. On the flip side, the San

Joaquin Valley had only 48 primary care physicians and 80 specialists for every

100,000 residents. The Inland Empire, a region in Southern California made up of

Riverside and San Bernardino counties, had only 43 primary care physicians and

77 specialists for every 100,000 residents.

“There are efforts underway to get more physicians to practice in those

areas,” said Robbin Gaines, a senior program officer for the CHCF. “But it’s going

to take a while.” One program provides doctors who recently graduated from medi-

cal school with up to $105,000 in student loan payments in return for practicing in

an underserved area of California for three years.

One trend in California’s favor is the percentage of medical school graduates

who choose to remain in California after they graduate. The study showed that

62% of students who attended medical school in California remained in the state

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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

Director, Provider & Ancillary Contracts / Network Management

Providence is calling a Director, Provider & Ancillary Contracts / Network Management to Providence Little Company of Mary in Torrance, CA.

IN THIS POSITION YOU WILL:

• Serve as a negotiator, resource and coordinator concerning existing and new provider and ancillary contracts, implementation of new policies, procedural and contractual guidelines.

• Be required to have strong analytical, financial and utilization modeling skills.

• Work closely with Providence Medical Associates physician management team, UM team, Business Development, and Payor Contracting Shared Services team.

REQUIRED QUALIFICATIONS FOR THIS POSITION INCLUDE:

• Master’s degree, or equivalent work experience• Minimum 3 years contracting experience in a health care setting• Knowledge of HMO/PPO financing concepts, health care market place,

health delivery systems, contract structure, terms and processes• Familiarity with hospital and medical group operations• Familiarity with compensation methodologies applicable in managed

care contracting, including case rates and specialty capitation• Strong quantitative and analytical skills• Ability to meet critical deadlines• Knowledge of pertinent State and Federal regulations including

DMHC regulations• Ability to create fee schedules, contracts and amendments, compose

letters, correspondence and create reports from databases• Ability to maintain data and keep up to date• Ability to assess impact of contract terms on claims auto-

adjudication rates• Proficient skills in reviewing contract language and tracking/monitoring

contracts• Outstanding interpersonal skills and negotiation skills• Knowledge of CMS and HIPAA regulations• Ability to handle multiple tasks including project management and

quantitative analysis• Strong negotiation, communication and customer service skills as well as

experience in working with physicians in contract discussions• Excellent Excel skills

PREFERRED QUALIFICATIONS FOR THIS POSITION INCLUDE:

• Experience in health care, business or related field• Medical group or IPA business• Extensive knowledge of personal computer and peripheral equipment

with MS Office and Access software

ANSWER THE CALL. Providenceiscalling.jobs When applying online, please reference job number 84313.

APPLY ONLINE: http://50.73.55.13/counter.php?id=36654

Providence Health & Services is an equal opportunity employer who provides competitive benefits, a drug-free workplace and supports work/life balance.

Claims ExaminerResponsible for accurate and timely adjudication of claims in accordance with applicable contracts, state and federal regulations, health plan requirements, Tenet policies and procedures, and generally accepted business practices. Position is based in Encino, CA.

Responsibilities: Proficiency in operation of Company’s software and hardware systems for claims adjudication. Excellent understanding of health and managed care concepts and their application in adjudication of claims. Ability to accurately assess financial responsibility and liability for claims submitted by members and providers. Accurate input of data required for claims adjudication including: diagnostic and procedural coding, pricing schedules, member and provider identification, and related information. Maintain 95 percent coding and financial accuracy.

Requirements: 1-3 years processing of managed care health claims. Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology. Ten Key by touch. Ability to type 40-45 words per minute. Ability to operate a PC. Previous exposure to Microsoft Windows environment.

Apply Today!

For confidential consideration and additional information, contactPatrick.Rentfrow@coniferhealth.com

Provider Contracting Competitive Insight & Market Research Sr. Specialist

CA, AZ, CO or WAThis high impact resource has its main focus around the analyzing of national and market research activities related to Field Contracting initiatives and strategies. Collects and analyzes data to identify market trends and potentials, competitive forces, penetration strategies, user biases and preferences and similar parameters of the marketplace. This position may be based in CA, AZ, CO or WA.

Bachelor’s Degree required; MBA or Master’s Degree in HealthCare Administration or health-related field preferred. Market research expe-rience preferred with concentration in healthcare industry analysis and business insights. Minimum of 5 years managed healthcare experience or network contracting preferred. Alternatively, will consider those with strong market research background and strong understanding of healthcare delivery systems.

For more information, please visit our careers page at www.cigna.com, job id 14001728 or contact nelia.ginder@cigna.com.

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

Claims SupervisorReporting to the Manager of Claims, this position will provide direction to the the Claims examiner team while monitoring daily workflows. Position is based in Encino, CA.

Responsibilities: Monitor inventory reports and assign work queues based on staffing and/or volume reassess. Identifies and distributes unprocessed work in established priorities. Contributes to daily production standards and output. Works collectively with management and staff to ensure compliance with inventory production and timeliness standards. Reviews daily operational reports as needed throughout the day to assure compliance. Maintains controls to insure that claims are processed within regulatory requirements. Identify training for staff failing to meet established minimum production and quality objectives. Responsible for staff orientation and training.

Requirements: 2-4 years experience in processing managed care health claims. Understanding of coding concepts (ICD9 CM, HCPCS, CPT, ASC, etc.). Working knowledge of managed care concepts and regulatory requirements. Understanding of word processing, spreadsheet applications. Microsoft Office experience is preferred.

Apply Today!

For confidential consideration and additional information, contactPatrick.Rentfrow@coniferhealth.com

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

BEHAVIORAL HEALTH SPECIALIST Req. #15-1750

DATA ANALYST SR. – HEDIS & MEDICARE STAR

Req. #14-1521, 15-1694

DATA ANALYST, SR – HEALTHCARE SERVICES Req. #15-1722

FACILITY SITE REVIEW NURSE Req. #15-1810

HEALTHCARE INFORMATICS ANALYST II Req. #14-1588

HEALTH PROMOTION RN Req. #15-1805

MANAGER DIGITAL STRATEGY Req. #15-1744

MANAGER QUALITY ASSURANCE & TESTING Req. #15-1779

PHARMACY ANALYST Req. #15-1739

PROJECT MANAGER Req. #15-1812

PROJECT MANAGER SHARED SERVICES Req. #15-1774

RECOVERY SPECIALIST Req. #15-1735

REG’L DIRECTOR, NETWORK MANAGEMENT Req. #15-1729

HOT SQL DATABASE ADMINISTRATOR Req. #14-1591

SR. BUSINESS ANALYST – DIGITAL STRATEGY Req. #15-1726

HOT SUPV CLINICAL REVIEW & AUDITOR Req #15-1778

SUPERVISOR (MSSP) – IAH REQ. #15-1775

SUPERVISOR PHARMACY - CDAG Req. #15-1787

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For a complete position description and to apply online,please visit our careers website at

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“Creating Healthcare Solutions”

Medical Director(Scotts Valley)

 Under direction, this position provides clinical leadership within one or more of the Health Services functional areas including, but not limited to: Utilization Management, Quality Improvement, Pharmacy, and Care Management and in addition, provides clinical leadership regarding provider relations, member relations, and regulatory compliance; develops and improves relationships with internal and external stakeholders, including the professional medical community and maintains and enhances communications with similar Health Plan organizations; and performs other duties as assigned.

This position requires a current unrestricted California license to practice Medicine and experience working in medical programs administration, peer review process, and supervising department staff.  Experience working with systematic quality assurance and improvement and public health and epidemiology programs is preferred. Board Certification is preferred.

Senior Director, Managed CareAdventist Health Managed Care is seeking an experi-enced managed care professional to support physician and home health contracting. The applicant will have system wide responsibility for negotiations of payer contracts and will collaborate in the development of strategic initiatives related to physicians and home health. A minimum of 5 years experience in successfully negotiating various types of physician, IPA and home health managed care contracts, developing revenue growth opportunities and establish-ing strategic alliances is necessary. A Bachelor’s Degree is required; Masters Degree preferred. The position will be based in either Ontario, CA or Roseville, CA.

Qualified candidates should email their resume with salary history to Martha.ibarra@ah.org.

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

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

VP, Quality ImprovementOversee all related activities for the Quality Improvement functions. Lead and direct process improvement activities for more efficient and streamlined workflow.

Responsibilities: Responsible for all activities related to National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance ensuring highest level of accreditation. Manage all aspects of HEDIS improvement activities, including outreach, incentives, data integrity and chart review. Review and implement new technological tools and processes and foster team concept with internal and external constituencies.

Education/Experience: Bachelor’s degree in Nursing or related clinical field. Master’s’ degree preferred. 10+ years of healthcare operations experience, including quality improvement and NCQA accreditation experience. Experience managing acquisition and integration of external data sources.

Manager, Care ManagementPerform duties to conduct and manage the day to day operations of the care management functions communicating with departmental and plan administrative staff to facilitate daily department functions.

Responsibilities: Manage the delivery of services to members, ensuring services are appropriate and cost effective. Ensure compliance with government and company requirements in the care management department. Develop and implement new procedures, regulatory filings and manage compliance issues. Develop, implement, and oversee care management policies and procedures and give specific guidance to staff and departments as appropriate.

Education/Experience: Education/Experience: Bachelor’s degree in Social Work, Sociology, Psychology, Nursing, Gerontology, related field or LPN/RN. 6+ of long term care related experience. Thorough knowledge of case and/or utilization management. Familiarity with Medicaid managed care practices and policies, CHIP, and SCHIP.

License/Certification: Valid driver’s license.I-NP1.

Vice President, Compliance Ensure regulatory compliance with state and other government agencies related to the health insurance industry, Centene Corporation, and its business subsidiaries.

Responsibilities: Ensure business unit and Centene Corporate are in compliance with state, federal program/insurance regulations, regulatory and state contract requirements. Maintain, track laws, regulations, contract documentations, amendments, and compliance measures. Develop policies, procedures, processes to comply with state/federal law, contract requirements, and standards. Oversee, administer, and implement compliance programs, including fraud and abuse and HIPAA. Provide guidance to departments regarding compliance issues, implementation of new requirements.

Education/Experience: Bachelor’s degree in Public Policy, Government Affairs, Business Administration or related field. Master’s or Law degree preferred. 8+ years compliance program management, contract experience. Extensive knowledge of state administrative code, regulations, state insurance laws, regulations including managed care regulations. Experience with state/federal government agencies, accreditation bodies, participating provider agreements, HIPAA and Third Party Administration (TPA) laws, credentialing regulations and prompt pay laws.

Manager Case ManagementConduct and manage day to day operations of case management, communicating with departmental and plan administrative staff to facilitate daily department functions.

Responsibilities: Review analyzes of activities, costs, operations, forecast data to determine progress toward stated goals, statistical/financial purposes. Promote compliance with federal, state regulations and contractual agreements. Develop, Implement, and Maintain: Compliance with medical case management policies and procedures; Case management programs to facilitate medical resources, decrease health plan financial exposure. Facilitate communication between case management staff, members, contracted providers, subsidiaries. Develop staff skills, competencies through training and experience.

Education/Experience: Bachelor’s degree in Nursing or equivalent experience. 3+ years case management experience, recent nursing experience in acute care setting (medical/surgical, pediatrics, or obstetrics). Thorough knowledge of case and/or utilization management, clinical nursing. Familiarity with Medicaid managed care practices and policies, CHIP, and SCHIP. Experience as lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing performance of staff.

License/Certification: Unrestricted RN license in applicable state(s) and valid driver’s license and automobile insurance. Case Management Certification (CCM) preferred.

Drug Utilization Review (DUR) Clinical PharmacistDefine and develop standard and custom drug utilization review (DUR) programs for all lines of business including Commercial, Medicaid, Health Information Marketplace and Medicare.

Responsibilities: Develop and implement DUR programs and various clinical pharmacy initiatives that promote quality, safety, cost of care opportunity and positive member outcomes. Develop and enhance DUR criteria and measures and overall clinical pharmacy program by assessing drug utilization trends, reviewing state and federal regulations, NCQA and HEDIS standards, primary literature review and current evidence-based clinical therapy guidelines and accepted standards of practice. Analyze drug utilization trends, identify gaps in care and inappropriate utilization and fraud, waste and abuse, and therapeutic interchange opportunities, and coordinate the development of appropriate protocols and guidelines. Develop clinical criteria and metrics for targeted DUR programs.

Education/Experience: Bachelor’s degree or advanced degree (PharmD., M.S) in pharmacy. 5+ years of managed care pharmacy experience, preferably with DUR related activities and clinical programs.

Licenses/Certifications: Current state’s Pharmacist license with no restrictions.

Data Analyst IIIResponsible for analytic data needs of the business unit. Handle complex data projects and acts as lead for other Data Analysts.

Responsibilities: Provide advanced analytical support for business operations in claims, provider data, member data, clinical data, HEDIS, pharmacy, external reporting. Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources. Review data to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management. Develop reports and deliverables for management. Model data using MS Excel, Access, SQL, and/or other data ware house analytical tools. Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analysis. Assist with training and mentoring other Data Analysts.

Education/Experience: Bachelor’s degree in related field or equivalent experience. 4+ years of statistical analysis or data analysis. Advanced knowledge of Enterprise Reporting and Analysis tools, SQL, and Microsoft Office applications, including Excel and Access. Experience managing projects or heavy involvement in project implementation. Healthcare experience preferred.

Please apply online at www.cahealthwellness.com and submit your resume to BRWILSON@CENTENE.COM

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

Bi-lingual (Vietnamese) Customer Services RepresentativeAssist Members, Provider, Health plan representatives by providing accurate information in a timely and courteous manner. Will also facilitate the process for Health-Education activities. Position is located in Westminster, CA.Responsibilities: Answers member telephone inquiries via ACD phone system. Maintains professional, courteous telephone etiquette. Logs calls in Customer Service Module that require action within Conifer Value Base Case (CVBC). Provides status on claims, authorizations, and eligibility to Providers, Health plans. Facilitates processing of claims appeals. Refers inquiries to departments as needed. Follows up on resolution of inquiries. Facilitates the resolution issues for providers as they relate to claims, authorization and eligibility inquiries. Maintains and keeps all files, documents and records that pertain to the operation of business of Cap Management Systems. Requirements: High School diploma or equivalent work experience. Two year minimum Customer/Member service experience, in a healthcare environment. Two year minimum ACD or comparable multi-line call center. One year medical claims processing experience, preferred. Knowledge of CPT, ICD-9, DRG, Revenue, HCPCS codes and HF1500, UB04 billing forms. Knowledge of financial responsibility delegation. Must be familiar with the authorization referral process. Knowledge of Medicare & Medi-Cal desirable. Computer literate, must have EZ-Cap experience. MS Word, Excel, Mail a plus. Must be able to type at least 80 wpm. Must speak fluent Vietnamese.

Apply Today!

For confidential consideration and additional information, contactPatrick.Rentfrow@coniferhealth.com

Gold Coast Health Plan is currently accepting applications for the following positions:

√ Director of Risk Management

√ Clinical Program Manager – Disease Management

√ Health Education Program Supervisor

√ Administrative Assistant

√ Cultural and Linguistics Specialist

√ Utilization Review, RN

√ Senior Decision Support Analyst

√ Facilities Manager

√ IT Business Analyst

√ Executive Assistant

All qualified candidates must submit an online application. Online applications and full job descriptions can be found at:

http://www.goldcoasthealthplan.org/about-us/careers.aspx

SFHP is a progressive managed care health plan designed by and for the people of San Francisco. We are a fast-paced, team-oriented organization that is growing due to recent healthcare reforms. We seek driven, committed, result-oriented professionals who are passionate about making an impact in the community. We thrive on our culture of serving with respect, striving to excel and teamwork.

• Director, Pharmacy

• Senior Project Manager

• UM Nurse, Clinical Quality and Outreach

• Business Solutions Analyst

• Manager, Health Services Business Relationships

• Project Manager / Business Systems Analyst

• Supervisor, Complex Case Management

Please apply through our career page at www.sfhp.org/careers

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

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

FEATURED OPPORTUNITIESExecutive Director, Network Management #321560Bachelor’s degree or equivalent/relevant experience required. Master’s degree preferred. Minimum 10 years of experience in a managed care environment with IPA’s, medical groups or HMO’s. 5 years direct experience in a Provider Relations role.

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

Director, Regional Clinical Ops North # 321312 Bachelor’s degree in Business Management, Health Care Administration, Nursing or other related field required. Master’s Degree preferred. 10 years complex management experience in an ambulatory setting that includes experience and knowledge of medical practice and clinical management.

Director Accounting & Compliance #321854Bachelor’s degree in Finance/Accounting require, CPA license strongly preferred. Minimum 5 years of experience managing a team of mid-level management, fluent in GAAP and strong experience in complex financial statement preparation, analysis, internal controls and current auditing techniques.

OPERATIONS• Clinical Project Manager• Practice Transform/Development Manager

• Medical Management Data Analyst• Business Integration Coordinator

INFORMATION SERVICES• Director of Applications & Project Support• Clinical Applications Specialist (OpTime))

• Business Systems Specialist (Tapestry)• And many more----------

CLINICAL• RN In-Patient Care Manager• Clinical Risk Manager

• RN Supervisors• Practice Manager

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