top stories state continues investigation into fraud at drug...
TRANSCRIPT
CUSTOMER SERVICE CEnTER E-mail Subscribers: If you do not receive your copy of HealthFax, send
a request to: [email protected]. For renewals or other subscription questions, please call: 800-753-0131. By fax: 866-592-7573. By e-mail: [email protected].
Published every Monday, California Healthfax is copyrighted by HCPro, 75 Sylvan St., Suite A-101, Danvers, MA 01923, and is transmitted solely to the subscriber. Any unauthorized copy-ing, duplication or transmission is strictly prohib-ited. Annual subscriptions are $159. For group and bulk subscriptions, call 800-753-0131.
EDITORIAL SUBMISSIOnSTo submit an item for consideration, con-tact Doug Desjardins, Editor. By e-mail:
[email protected]. By phone: 760-294-5985. For other questions, contact Bob Wertz, Managing Editor. By phone: 800-639-7477, ext. 3456. By e-mail: [email protected]
ADVERTISIng OppORTUnITIEST o a d v e r t i s e i n C a l i f o r n i a Healthfax, please contact Susan by
e-mail: [email protected]. By fax: 800-698-2082. By phone: 888-834-4678.
PAgE 1 of 5September 11, 2006
« ConTInuED on PAgE 2 »
August 19, 2013 | VoluME 20 | nuMBEr 31
t o p S t o r i E S
State Continues investigation into Fraud at Drug treatment Centerspayments suspended to 108 facilities so farState health officials are continuing their investigation into fraud at Medi-Cal–funded drug and alcohol rehabilitation centers after suspending Medi-Cal pay-ments to more than 100 facilities.
The state Department of Health Care Services (DHCS) has already sus-pended payments to 38 companies operating 108 drug and alcohol rehabilitation centers in the state that are part of the Drug Medi-Cal program. The DHCS is working with the Department of Justice on an investigation that will review billing irregularities and employment practices at more than 1,000 treatment centers in the state.
“We have people visiting the drug and alcohol rehab centers every day and, if they find evidence of more fraud, there will be more suspended payments,” said Norman Williams, a spokesman for the DHCS. He said Medi-Cal patients who were receiving treatment at centers where payments were suspended are being re-directed by county health officials to other facilities nearby to continue their treatment. There are currently 1,064 centers in the state that are part of the Drug Medi-Cal program.
The ongoing investigation and allegations of rampant fraud have prompted calls for more investigations and more stringent oversight of the program that helps people with serious substance abuse problems. Los Angeles County Supervisor Zev Yaroslavsky introduced a motion last week calling for county auditors and attorneys to audit drug and alcohol treatment centers in los Angeles County and return with a report within 30 days, calling the allegations of fraud “an embarrassment for all concerned.”
State Sen. ted Lieu (D-Los Angeles) has requested that the state Joint Legislative Audit Committee conduct an audit of all drug and alcohol rehabilita-tion centers in the state that receive Medi-Cal funding. “I represent los Angeles, where many examples of fraud apparently occurred,” said lieu. “The alleged fraud in the Drug Medi-Cal program is not only outrageous, but is potentially
Executive Compensation: New Metrics and Skill Sets
95% of leaders say more incentives must be based on clinical quality performance
Click now to download!
PAgE 2 of 13 August 19, 2013
Medical Staff Leadership Seminars by The greeley Company
Visit www.greeley.com, or Call 800-801-6661
« ConTInuED on PAgE 3 »
t o p S t o r i E S ConTInuED FroM PAgE 1
» Corona regional Medical Center plans to close its pediatric unit on Sept. 6. “This has been a very difficult deci-sion but one made with the input of our local pediatrician and physician lead-ership,” said Kevan Metcalfe, CEo of Corona regional Medical Center. “We see very few children who require inpa-tient hospitalization at the level of care we provide. But we are very fortunate in Corona to be located among a num-ber of high-level pediatric facilities.” Corona regional, a 160-bed acute care hospital, will continue to provide emer-gency care for children.
» Th e C a l i fo r n i a H e a l t h C a re Foundation (CHCF) has named Sandra Hernandez, MD, as its new president and CEo effective Jan. 2. Hernandez is currently CEo of the San Francisco Foundation. “We are at a critical junc-ture in our nation’s history with the implementation of the Affordable Care Act,” said Hernandez. “California will be a vanguard state in implementing these measures and this is an incred-ible opportunity to improve healthcare.” Hernandez will replace Mark Smith, MD, who will step down as CEo after 17 years with CHCF. “Passing the baton to Sandra Hernandez gives me great pleasure,” said Smith. “I have admired her work both from afar and up close at San Francisco General Hospital, where we have both practiced medicine together for many years.”
» temecula Valley Hospital held an open house at its new facility on Aug. 10 in advance of a planned opening in
i N B r i E F
« ConTInuED on PAgE 3 »
For subscription services, call 800-753-0131
damaging to efforts to utilize rehabilitation as a solution to California’s incarcera-tion and drug abuse problems.”
lieu cited an instance in which a treatment center counselor told investi-gators that a clinic billed Medi-Cal for 179 patients even though it had only 30. other anecdotes include instances in which people without drug problems were paid to show up at facilities so that the clinics could bill Medi-Cal and clinics that billed Medi-Cal for treating patients who had died.
The Drug Medi-Cal program was overseen by the state Department of Alcohol & Drug programs until July 2013 when it was placed under the supervi-sion of DHCS. Williams said DHCS began noticing billing irregularities and other problems that indicated some centers were engaged in questionable practices. “After taking over the program, DHCS began to see things that were disturb-ing,” said Williams. “And that’s what led to the investigation.” The Center for Investigative Reporting has also been conducting a separate investigation into allegations that clinics were engaged in fraudulent practices.
regardless of what happens with the rest of the investigation, Williams said the DHCS will require all treatment centers that are currently part of the Drug Medi-Cal program to fill out a new application in order to receive Medi-Cal funding. “Everyone is going to have to re-apply to be part of the program,” said Williams. “And that process will include having someone from DHCS visit and review each clinic to make sure their services are adequate.” He said the re-appli-cation process is expected to take 18 months to complete. —Doug DesjarDins
Bills to Expand Scope of Service for pharmacists and Nps Advancethird bill to expand role of optometrists is shelvedTwo bills that would expand the scope of service for pharmacists and nurse prac-titioners were approved by a state Assembly committee last week.
The Assembly Committee on Business, professions, and Consumer protection voted 8-3 to pass Senate Bill 491, which would expand the scope of service for nurse practitioners. The same committee voted unanimously to approve Senate Bill 493, which would expand the scope of service for pharma-cists. The bills authored by Sen. Ed Hernandez (D-West Covina) will move to the Assembly Appropriations Committee for consideration later this month.
Senate Bill 492, which would expand the scope of service for optometrists, was pulled from consideration and will be revisited in 2014. “There were some concerns that
State Continues cont.
Place YourAd Today!
Promote a Company Event or Advertise Your Products and Services NOW!
Contact Susan at 888-834-4678or [email protected] rates, availability, and special offers!!!
i N B r i E F Continued from page 2
September. The $150 million hospital built by pennsylvania-based Universal Health Services will cover 177,000 square feet and feature 140 beds in pri-vate rooms, an emergency department, five surgical suites, and a 20-bed inten-sive care unit. Hospital officials said the hospital should be ready to open after the California Department of public Health conducts its final inspection in late August. Temecula Valley Hospital will be the first hospital built in the city of Temecula.
» The California Department of public Health has awarded Anthem Blue Cross a contract to provide Medicaid managed care for beneficiaries in 19 counties under the state’s rural Expansion plan. Anthem currently pro-vides Medicaid managed care in 10 coun-ties in the state and the new contract will bring that total to 29. “Anthem is pleased to continue our long-standing partnership with the state as it pre-pares to expand managed care benefits in some of the state’s most rural areas,” said Steve Melody, regional vice presi-dent of Anthem’s Medicaid business. under the contract, Anthem will expand its service area later this year to Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, inyo, Mariposa, Mono, Nevada, placer, plumas, San Benito, Sierra, Sutter, tehama, tuolumne, and Yuba counties.
» Sharp Mary Birch Hospital for Women & Newborns has opened a new Neonatal research institute. The institute will be led by Anup
« ConTInuED on PAgE 4 »
For subscription services, call 800-753-0131
t o p S t o r i E S ConTInuED FroM PAgE 2
Bills to Expand cont.
HIRE POWER: HEALTHFAx CLASSIFIED ADS WORK!
CALL 888-834-4678
needed to be worked out so Sen. Hernandez pulled SB 492 and made it a two-year bill,” said Janet Chin, director of communications for Hernandez.
Hernandez introduced the trio of bills earlier this year as part of an effort to prepare the state for an influx of new patients under federal healthcare reform. Hernandez said the bills are geared to help ease a potential shortage of primary care physicians in the state. “If we’re going to mandate that everyone needs to have health insurance, we need to follow through and make sure there are enough healthcare providers to treat them,” said Hernandez.
In order to gain approval for SB 491, Hernandez amended part of the bill that would have given nurse practitioners the authority to practice without phy-sician supervision. The bill will now require nurse practitioners to “work in a col-laborative setting” with physicians. Hernandez said the amendment is designed to “find common ground” with legislators who expressed concerns about nurse practitioners operating independently. The bill was also amended to exclude a provision that would have allowed nurse practitioners to practice independently after three years of working under the supervision of a physician.
Despite the amendments, the California Medical Association (CMA) said it is still opposed to SB 491. In a statement, CMA president paul phinney, MD, said that “SB 491 will only further fragment the healthcare delivery system at a time when highly integrated delivery models are vital. SB 491 will also give nurse practitioners the authority to prescribe drugs like oxycodone without supervision.”
The CMA has taken a neutral position on SB 493 after the bill was amended to eliminate a provision that would have allowed pharmacists to independently prescribe what it described as “dangerous smoking cessation drugs such as Chantix.” Hernandez envisions a scenario in which pharmacists will be able to help patients with chronic health conditions such as diabetes and hypertension manage their conditions and oversee their medication regimes.
legislators this month are also due to consider Assembly Bill 900, which would prevent the state from implementing 10% Medi-Cal cuts to distinct part skilled nursing facilities. The bill is sponsored by the California Hospital Association (CHA), which said the cuts could force some units to shut down completely and leave elderly and chronically ill people with few alternative care settings, particularly in rural areas of the state.
“The patients being cared for in these facilities typically require specialized, medically complex care that freestanding nursing homes and other healthcare providers will not or cannot provide,” said CHA president C. Duane Dauner. He added that some hospitals are already scaling back services at skilled nursing units in anticipation of the cuts. —Doug DesjarDins
PAgE 3 of 13 August 19, 2013
SUBSCRIBE TODAY and drill down into data by:
Intelligence Report PREMIUMSetting Beds Sites Revenue Region
What Are Organizations Just Like Yours Doing on Key Issues?
Medical Staff Leadership Seminars by The greeley Company
Visit www.greeley.com, or Call 800-801-6661
i N B r i E F Continued from page 3
Katheria, MD as its new director of neonatal research. “Dr. Katheria will continue to expand our active clini-cal neonatal research program into his research interests, including delivery room resuscitation, delayed cord clamp-ing, and functional echocardiography,” said trisha Khaleghi, CEo of Sharp Mary Birch Hospital for Women & newborns in San Diego. The neonatal research Institute has already received a $155,000 grant from the National institutes of Health for its first research project, which will study later clamping of the umbilical cord and how the procedure may benefit newborns.
» UnitedHealthcare awarded St. Joseph Hospital in orange a $710,252 grant to help it build an electronic health record (EHr) system that will connect the 525-bed hospital with 27 commu-nity clinics located throughout orange County. The EHr system is designed to expedite the referral process for patients at community clinics and provide more coordinated care. “We’re grateful for the generosity of unitedHealthcare,” said Steven C. Moreau, president and CEo of St. Joseph Hospital. “The implemen-tation of our electronic health record system with all of our community part-ner clinics will provide better access to patient medical records and, ultimately, improve the quality of care for clinic patients.”
» A 29-year-old woman was arrested Aug. 12 for posing as a nurse at Santa Clara Valley Medical Center in San Jose. According to a report in the San
« ConTInuED on PAgE 5 »
For subscription services, call 800-753-0131
t o p S t o r i E S ConTInuED FroM PAgE 3
PAgE 4 of 13 August 19, 2013
Covered California opts to Not include insurer ratings on WebsiteSeveral insurers urge board to reconsider decisionCovered California officials said the health insurance exchange will not include heath plan ratings when it launches in october, a decision that isn’t sitting well with some healthcare advocates and insurers.
At its Aug. 8 meeting, the Covered California board of directors decided that the ratings compiled by the state office of the patient Advocate (oPA) would not accurately reflect the coverage provided under new plans offered on Covered California. officials said many insurers have altered their plans since 2011—the year the most current ratings are based on—and that the ratings will not reflect the content of the plans.
“These factors raise substantial concerns that the historical performance of plans may not be representative or complete enough to allow for direct compari-sons,” said peter Lee, executive director for Covered California. lee said Covered California plans to eventually create a health plan rating system of its own.
The decision to exclude the ratings was criticized by consumer advocacy group Health Access California, which said it would be better to provide consumers with some guidance even if it is incomplete. Kaiser permanente, Sharp Health plan, and Western Health Advantage also issued a joint letter to Covered California board members urging them to reconsider the decision at their next meeting on Aug. 22.
Covered California was expected to include the oPA ratings as part of its website. The ratings rank HMos and PPos in the state in several categories that include whether insurers provide recommended levels of care. Kaiser was the top-ranked insurer in the 2011 ratings.
The Covered California board also announced the final lineup of insurers that will sell health plans to individuals and small businesses on the exchange. The list includes Alameda Alliance for Health, Anthem Blue Cross, Blue Shield of California, Chinese Community Health plan, Contra Costa Health plan, Health Net, Kaiser permanente, L.A. Care Health plan, Molina Healthcare, Sharp Health plan, Valley Health plan, and Western Health Advantage.
one insurer not on the final list is Ventura County Health Care plan. The regional provider was selected to sell plans on the individual market by Covered California in May but was not on the final list issued this month. neither Covered California nor Ventura County officials provided a specific reason for Ventura’s departure but lee said Covered California is in negotiations to have Ventura County Health Care Plan be part of the exchange in 2015. —Doug DesjarDins
Get research-based insights into what physicians want Based on an in-depth survey of nearly 200 physicians
www.healthleadersmedia.com/HealthLeaders-Books
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
For subscription services, call 800-753-0131
i N B r i E F ConTInuED FroM PAgE 4
HIRE POWER: HEALTHFAx CLASSIFIED ADS WORK!
CALL 888-834-4678
Jose Mercury News, Crystal Cook was arrested after she was discovered walking around the hospital wearing scrubs, a fake registered nurse badge, and a stetho-scope. Hospital officials said Cook was not able to access any secure areas of the hospital and was booked on misdemeanor charges by the Santa Clara County Sheriff’s office. Authorities said it’s unclear why Cook was impersonating a nurse at the hospital.
» Covered California plans to open its Fresno call center in an office building that currently serves as a call center for Bank of America. According to a report in the Fresno Bee, Covered California plans to start moving into the 54,600-square-foot office building in late August after Bank of America moves out. Fresno city officials said they’re pleased that Covered California will fill the void left by Bank of America, which employed 543 people at its call center. “It was a little ray of sunshine when Covered California told us they wanted to come in and take over that building and offer a bunch of jobs,” said Georgeanne White, chief of staff for Fresno mayor Ashley Swearengin. The call center is expected to employ about 500 workers who will field calls and answer questions from consumers about coverage options avail-able on the Covered California health insurance exchange. Covered California also plans to open call centers in rancho Cordova and Contra Costa.
» Brown & toland physicians and SCAN Health plan have expanded their man-agement agreement to allow Brown & Toland to manage both physician and hos-pital services for SCAn members. under the new contract, members of SCAn—a Medicare plan with 145,000 members in California and Arizona—will continue to have access to San Francisco-based Brown & Toland’s network of more than 1,500 physicians and to hospitals that include California pacific Medical Center, Saint Francis Memorial Hospital, and St. Mary’s Medical Center. “SCAn has more than three decades of experience in developing innovative programs and services that support healthy aging,” said Karen Sugano, SCAn’s general manager for northern California. “This expanded relationship provides a great opportunity for our organi-zations to work together to develop programs that could make a significant, positive impact in the lives of many of our members.”
» The California Department of Healthcare Services (DHCS) announced the state will begin implementing 10% rate cuts to Medi-Cal in September. The cuts will go into effect on Sept. 5 for dentists and medical transporters and then for medical equipment and supplies on oct. 24. The last providers to be affected will be physi-cians, pharmacists, and distinct-part skilled nursing facilities on Jan. 9, 2014. The cuts were originally planned to go into effect in 2011 with the passage of Assembly Bill 97 but were blocked by lawsuits until June 2013, when the Ninth U.S. Circuit Court of Appeals issued a ruling allowing the state the enforce the cuts. A bill cur-rently being considered by the state Senate, Assembly Bill 900, would block cuts to skilled nursing facilities if it’s approved.
E V E N t S
PAgE 5 of 13 August 19, 2013
get your event listed in Healthfax! E-mail the details to:
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 6 of 13 august 19, 2013
Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. We serve over 600,000 members in Riverside and San Bernardino counties in Medi-Cal, Healthy Kids and a Medicare Special Needs Plan. Our success is attributable to our Team who share the IEHP mission to organize the delivery of quality healthcare services to our members. Join our dedicated Team!
cLaiMs processinG ManaGer
The Claims processing Manager oversees medical claim pro-cessing activities and personnel to ensure that hospital and professional claims are accurately administered within regu-latory and contractual standards. 5 or more years of super-visor/managerial experience in a medical claims department. In-depth knowledge of DMHC, DHCS, CMS claims payment requirements and policy formulation preferred, division of financial responsibility (DOFR), facility and professional authorization and claim adjudication requirements, inventory management & reporting, claims processing systems-includ-ing system conversions, workflow development and regula-tory audit coordination. experience in an HMO or managed care environment administering Medi-Cal and/or Medicare programs strongly preferred.
proven leadership skills with demonstrated ability to man-ager high volume claim processing activities to ensure prompt payment requirements and compliance are attained. Develops and implements operational policies, workflows and process improvement initiatives. ability to develop cohesive work relationships and incorporate team building strategies. ability to manage a BpO relation-ships. Strong personnel management, time management and skills to oversee multiple projects. Detail oriented and results driven. Strong oral and written communication skills and knowledge of Microsoft applications required. Bachelor’s degree preferred.
coMpLiance ManaGer
The Compliance Manager for Regulatory analysis is responsible for review and analysis of incoming contract and regulatory changes for the purpose of summarizing and communicating their impact to pertinent departments and units. Responsible for monitoring and tracking department compliance and assists department management in devel-oping their internal audit and monitoring processes and keeping them current by adding/deleting criteria in compli-
ance with legislative changes. Strong interpersonal skills to communicate and resolve compliance issues with internal and external contacts.
Minimum of 2 years experience in healthcare; emphasis on compliance, risk management and/or auditing preferred. experience with healthcare auditing processes, and Medicare requirements preferred. Bachelor’s degree required, Masters preferred. professional Credentials such as a Certification in Healthcare Compliance (DHC); Certified professional Healthcare Quality (CpHQ); Registered Health Information administrator (RHIa); Registered Nurse (RN); preferred. experience in Microsoft applications.
Valid Ca Driver’s License and willingness to travel to audit and/or teaching sites.
HeaLtHcare anaLYsis ManaGer
Required experience in a Managed Healthcare environment with expertise in Financial analysis, Medi-Cal, Medicare, Capitation and Contracts. Responsible for monthly process-ing of Capitation and premium Billing, which involves complex data analysis, revenue reconciliation, problem resolution and reporting. Qualified candidate should possess strong analyti-cal skills and extensive experience with Microsoft access and SQL DML. ability to interact with all levels of management and establish and maintain strong business relationships.
Bachelor’s degree required. 5 years experience in a Managed Healthcare environment with expertise in Financial analysis.
IEHP offers a competitive compensation and benefits package. Please apply on-line:
inLand eMpire HeaLtH pLan, san Bernardino, ca
please Visit our website at www.iehp.org to get more information on our relocation to Rancho Cucamonga. eOe
.
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 7 of 13 august 19, 2013
applecare Medical Management is committed to providing the high-est 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 net-work management and provider relations. Candidates should have a minimum of 5-10 years of experience in managed health care that includes extensive experience in network management and provider relations. Must have solid working knowledge of con-tracting, finance, information technology, and/or utilization/case management.
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.
For immediate consideration, please email/fax resume with salary requirements: [email protected] or Fax 714.443.4540
Vp of network
ManaGeMentdirector, 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].
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
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 8 of 13 august 19, 2013
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].
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 9 of 13 august 19, 2013
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
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].
Read By Top Healthcare Management Professionals
to promote your organization’s events, products, or services
call susan @ 888-834-4678
ore-mail: [email protected]
Rate card and special offers ARE available!
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
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 10 of 13 august 19, 2013
ipa directorOur Ipa Director will provide staff leadership, plan, direct, manage and oversee the activities and operations of all departments including utilization review, claims and provider relations. We are looking for a leader who will develop and implement policies, procedures and quality customer service guidelines. This executive level full time position reports to the Vice president and is located in the city of Los angeles, Ca.
Duties include the following: Manage and negotiate all health plan contracts for Ipa including timely renewal and monitoring of product performance. Continuous review of all reports provided by the I.S. department including enrollment, pMpM, encounter data, etc. Review of capitation yield and trend reports provided by I.S. monthly. preparation and facilitation of monthly Ipa Board meetings. attendance as needed at Utilization Management and Quality Improvement meet-ings. prepare and facilitate provider meetings as directed by Ipa Board of Directors. Collaborate with Director of Risk adjustment on activities to increase incoming revenue, including provider training, provider outreach, development of procedures, etc. Work with BOD as needed. Supervise the investigation of facts and coverage, documentation, evaluation, and payment of claims process. attend all health plan JOC meetings and follow through on any action items. Collaborate with the Director of Medical Management on the application of benefits, utilization of appropriate ancil-lary provider network, documentation and decision-making process in the utilization management department as it relates to management of respective Ipa. ensure network adequacy and negotiate provider contracts as needed. ensure that prompt professional service is provided to insured, third parties claimants and agents. perform other duties as assigned.
MINIMUM ReQUIReMeNTS: Bachelor’s degree from an accredited university required, master’s degree preferred. 3-5 years’ experience in a managerial position in health care, extensive clinical experience and licensure preferred. Knowledge of health plan contracting and provider contracting. Comprehensive knowledge of utilization management processes.
Hiring Bonus Offered For the Right Candidate. please submit your resume to [email protected].
Built from more than 100 years of collective experience in the managed care industry, our IPA Management Company serves medical providers throughout the Southern California region. We offer a comprehensive benefits package including full health insurance, paid time off, short and long term disabil-ity, partially paid dental, vision and group life insurance, nine paid holidays and a friendly office environment.
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 seek a qualified candidate for the newly created Manager of network Management position. Responsibilities: Manage functions relating to provider servicing, provider education and network devel-opment per Network territory. Manages provider Services Team, (provider Relations Reps, In-House Coordinator, other provider asso-ciates). 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. 5 Years managed care experience. Minimum one year leadership/management experience.
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.
For immediate consideration, please email resume with salary requirements to [email protected]
ManaGer of network
ManaGeMent
contact susan: pHone: 888-834-4678fax: 781/[email protected]
You’re in Good Company When You Advertise in California Healthfax!
Place your ad today!
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 11 of 13 august 19, 2013
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 officerdirector of Health services
Health services informatics specialistcompliance specialist- delegation oversight
i.t. Business systems analystMember services data analyst
Qi- facility site review rnsenior policy analyst
sr. provider claims analystMember services representative i
outreach coordinator
For more information, please visit our website at: www.goldcoasthealthplan.org/about-us/careers.aspx
Contact: Stacy Diaz, Human Resources [email protected]
coMpLiance officer
america’s largest public health plan seeks strong and energetic talent to help us prepare for health care’s next transformation. We’re seek-ing a high caliber individual to be our Compliance Officer during one of the most significant times in the history of health care. This essential person will lead and grow with us as we expand our product lines and services to help L.a. County’s Medi-Cal, Medicare and Covered California populations.
This individual must be well-versed in regulatory and compliance issues with at least 5 years in progressively responsible roles in health care, insurance or a related field, with 5 or more years experience in managed care compliance. proven leadership maintaining a tightly run, high-demand environment is essential. Must be dynamic, person-able and able to be a senior leader of the health plan’s management team and serve as the point for all compliance activities with dotted line reporting to the CeO and Board of governors. Must have either Mpa, MBa, MpH, or MSC; Health Care Compliance Certification is a plus.
To apply and for complete job description, requirements/ qualifications, please visit our website www.lacare.org.
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
nurse practitioners Requisition # 13-1078
For more information, please visit our website at: www.scanhealthplan.com/about-scan/resources/job-postings
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
f e a t u r e d c a r e e r o p p o r t u n i t i e s
page 12 of 13 august 19, 2013
director, Bpo serVices Oversee implementation, ongoing oversight and management of Business process Outsourcing (BpO) services with vendor to support successful administration of QHp and other lines of business. act as Ca exchange operational liaison on behalf of the plan. Requirement: Complete understanding of state/federal requirements for commercial health plans, state-based exchange requirements, QHp and other product specifications, vendor management and health plan opera-tions. Ba/BS in Computer Science or related field. Minimum three years’ experience managing health care information systems such as claims processing systems, enrollment, medical management, and application processing systems.
superVisor, Bpo cLaiMsResponsible for ensuring Business process Outsourcing (BpO) claims are processed, adjudicated in date order and by claim type within appropri-ate 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 knowledge 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
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
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
ADVERTISE YOUR PRODUCTS
& SERVICESNOW!
pLace YourrecruitMent ad todaY!
RUN YOUR COMPANY
EVENT
email [email protected] or call 888-834-4678
to place a listing, please call 888-834-4678
For subscription services, call 800-753-0131
e M p L o Y M e n t o p p o r t u n i t i e s
page 13 of 13 august 19, 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
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]