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  Director, Configuration  

  L.A. Care Health Plan

  - Los Angeles

  Posted: 04/06/2026

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  Salary Range: $135,136.00 (Min.) - $175,676.00 (Mid.) - $216,218.00 (M... Read More

  Salary Range: $135,136.00 (Min.) - $175,676.00 (Mid.) - $216,218.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Director, Configuration develops and leads the strategy, execution, and continuous enhancement of authorization, benefit, pricing, provider, and configuration governance framework across L.A. Care's core administrative platforms (QNXT) and associated tools. This position ensures that configuration is accurate, efficient, and designed to function as a preventative control mechanism mitigating downstream defects by strengthening upstream processes, validating requirements, and building predictable, repeatable system behaviors. The Director oversees the full configuration life cycle - from impact assessment and requirements analysis through design, build, testing, and post-implementation validation, ensuring that changes are implemented with discipline and high reliability. The Director partners closely with cross-functional teams and other operational departments to ensure configuration supports a high-performing claims environment with strong control points, reduced rework, and timely, accurate adjudication. The Director is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes. The Director drives skill development, accountability, and operational consistency within the team. This position also serves a key role in supporting enterprise initiatives that require coordinated, scalable, and well-governed configuration changes. Duties Develops, and implements standards, quality gates and governance frameworks. Ensures that the core system configuration is executed with rigor, transparency, and precision. Strengthens upstream quality and operational readiness by leading disciplined change processes, anticipating downstream impacts, and establishing a consistent framework that reduces defects, improves accuracy, and enhances the reliability of the claims environment. Through active planning, structured governance, and strong cross-functional partnerships, ensures configuration supports a more standardized, predictable, and efficient operational ecosystem. Oversees the end-to-end configuration life cycle including analysis, requirements validation, design, build, testing, migration, and post-deployment monitoring. Establishes standardized processes, documentation requirements, and quality gates to ensure accuracy, traceability, and reliable execution of configuration changes. Ensures configuration solutions support accurate adjudication and align with operational needs, regulatory requirements, and enterprise readiness. Leads development and maintenance of configuration standards, controls, and governance frameworks that promote consistency and reduce manual rework. Collaborates with cross functional teams on configuration priorities, impacts, and implementation timelines. Partners in configuration quality assurance (QA) activities to validate accuracy, completeness, and compliance with internal standards and regulatory expectations and to ensure clarity of requirements, appropriate test scenarios, and full understanding of configuration logic. Supports operational readiness by coordinating clarification, defect research, requirement updates, and post-deployment validation support. Ensures configuration work meets established quality gates. Leads issue identification and root-cause analysis for configuration-related errors, ensuring sustainable upstream fixes. Establishes and monitors process-level controls that prevent recurring defects and improve configuration accuracy over time. Tracks and trends configuration errors, collaborating on remediation planning, systemic improvements, and prevention strategies. Duties Continued Oversees benefit configuration, pricing methodologies, provider reimbursement logic, and other adjudication rules requiring technical precision. Ensures configuration environments support stable performance, controlled releases, and effective integration with system enhancements and updates. Partners with key stakeholders to support migrations, module updates, automation opportunities, and system changes that strengthen functional performance. Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively. Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals. Identifies and actualizes enhancements to support company vision. Develops and maintains relationships with key stakeholders. Leads discussions on policy operationalization and oversees key policy perspective sharing. Leads, trains, and develops staff, ensuring technical competence, consistency, and high-quality execution. Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement. Performs other duties as assigned. Education Required Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Master's Degree in Business Administration or Related Field Experience Required: At least 7 years of experience in a system configuration or managed care operations involving core administrative platforms (e.g. Cognizant QNXT). At least 5 years of experience leading, supervising and/or managing staff in technical or operational environments. Significant experience configuring benefits, pricing methodologies, provider payment logic, and related adjudication rules. Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies. Advanced knowledge of and experience with American Health Information Management Association (AHIMA) coding standards. Knowledge of and experience with utilizing Systems Development Life Cycle (SDLC), configuration change management methodologies, testing protocols, document standards, and best practices. Experience supporting audits, corrective actions, and regulatory reviews. Skills Required: Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability. Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. Knowledge of SDLC procedures in planning system configuration changes (i.e., use of rigorous documentation, testing and quality assurance protocols prior to deployment of changes into production). Advanced knowledge of standard programming and logic to facilitate the maintenance of system configuration files and tables, along with supporting documentation. Strong ability to translate regulatory requirements and operational needs into clear, accurate system configuration. Exceptional analytical, planning, organization, and communication skills. Exceptional presentation skills, written and verbal communication skills, including executive communication skills with the ability to produce audit-ready documentation. Proficiency with Microsoft Office and data/reporting tools. Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization. Demonstrated ability to make sound and timely decisions. Demonstrated ability to adapt to changing situations and adjust strategies accordingly. Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change. Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations. Licenses/Certifications Required Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including * Paid Time Off (PTO) * Tuition Reimbursement * Retirement Plans * Medical, Dental and Vision * Wellness Program * Volunteer Time Off (VTO) Nearest Major Market: Los Angeles Job Segment: Claims, Medical Coding, Insurance, Healthcare Read Less

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  Clinical Policy Clinical Coder RN II  

  L.A. Care Health Plan

  - Los Angeles

  Posted: 03/06/2026

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  Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (M... Read More

  Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Clinical Policy Clinical Coder RN II is responsible for analyzing, interpreting, and operationalizing medical and utilization management policies to ensure accurate coding, appropriate authorization requirements, compliant claims processing, and effective utilization oversight. This position serves as a key clinical and coding resource, translating medical policy requirements into diagnosis, procedure, and service code logic, including determining which codes require prior authorization. Conducts in-depth research and analysis of legislation and regulatory requirements, clinical outcomes, utilization, claims, and financial data to identify utilization trends, fiscal risk, and opportunities for policy enhancement and cost containment. This position works cross-functionally with internal teams to ensure policies are codified, consistently applied, and monitored through reporting and data analysis. This position collaborates closely with internal stakeholders and external entities to support standardized benefit administration, effective program implementation, and organizational compliance with state, federal, and accreditation requirements. Duties Translate approved clinical policies and utilization management criteria into clear, codified claims rules and system logic to support accurate claims adjudication. Develop, revise, and recommend clinical policies and internal utilization management criteria when standard clinical guidelines are insufficient to support appropriate decision-making based on codified claim rules. Assess the downstream claims impact of new or revised clinical policies prior to implementation and recommend configuration updates to mitigate operational or financial risk. Participate in validation of claims configuration changes to ensure policies are applied correctly and consistently across all lines of business. Monitor post-implementation claims activity to identify configuration issues, unintended denials, or payment discrepancies related to clinical policy application. Support remediation of claims configuration defects by identifying root causes and coordinating corrective actions with internal teams. Participate in and lead specialty and cross-functional workgroups and committees focused on healthcare services clinical policies, utilization management processes, strategic initiatives, policy governance, operational alignment, and continuous improvement efforts. Ensure timely dissemination of accurate and consistent policies and procedures across departments. Promote collaboration, engagement, and a positive work environment while supporting departmental initiatives and team-based activities. Manage assigned projects from concept through implementation, ensuring timelines, quality standards, and deliverables are met. Analyze and interpret medical and utilization management policies to identify applicable diagnosis, procedure, and service codes and determine authorization, pre-payment, or post-payment review requirements. Define and maintain code lists that require prior authorization or other utilization management controls based on clinical evidence, regulatory guidance, utilization trends, and financial risk. Duties Continued Collaborate with internal teams to ensure authorization requirements and coding logic are accurately configured in authorization and claims systems based on authorization matrix requirements. Support accurate claims processing by validating codified authorization and policy requirements are correctly applied and aligned with approved medical policies. Provide clinical and coding recommendations to support the development, revision, and implementation of new or updated medical and utilization management policies. Investigate and resolve coding and authorization related issues, including claim denials, coding edits, authorization discrepancies, and policy interpretation questions. Review and assess claims edits, authorization matrixes, and coding rules to identify root causes of errors or inconsistencies and recommend corrective actions. Ensure coding, authorization requirements, and claims-related guidance align with medical necessity criteria, benefit structures, and applicable state, federal, and regulatory requirements. Develop, review, and maintain reporting related to authorization required codes, approval and denial rates, utilization patterns, claims payment outcomes, and policy effectiveness. Prepare reports, summaries, and presentations and communicate findings, recommendations, and action plans to internal and external stakeholders. Analyze claims, authorization, and utilization data to identify trends, measure policy impact, and recommend opportunities for policy refinement, cost containment, or reduction of administrative burden. Monitor post-implementation performance of authorization-required codes and recommend additions, removals, or modifications to authorization requirements based on regulatory thresholds and utilization outcomes. Perform other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 8 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Experience with medical coding systems. Preferred: At least 1 year of experience in editing and writing clinical health services policies within a managed care health plan. Skills Required: Proficient with clinical policy through skills in literature searching and clinical research analysis based on the best available evidence. Working knowledge of clinical policies. Working knowledge of CPT/HCPC codes and claims. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong analytical, problem solving, and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Ability to identify discrepancies, assess risk, and recommend actionable solutions. Knowledge of medical coding systems, including ICD-10-CM, CPT, and HCPCS, and their application in authorization and claims environments. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Proficient in claims configuration, including claims adjudication workflows, configuration of claims edits and rules, and the translation of clinical and utilization management policies into system-based claims logic to support accurate, compliant payment outcomes. Understanding of the managed care industry and market conditions. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Professional Coder (CPC) Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including * Paid Time Off (PTO) * Tuition Reimbursement * Retirement Plans * Medical, Dental and Vision * Wellness Program * Volunteer Time Off (VTO) Nearest Major Market: Los Angeles Job Segment: Nursing, Medical Research, Clinical Research, Medical Coding, Claims, Healthcare, Insurance Read Less

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  Manager, Financial Compliance Audit, $10,000 SIGN ON BONUS  

  L.A. Care Health Plan

  - Los Angeles

  Posted: 03/06/2026

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  Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (M... Read More

  Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary Manager, Financial Compliance Audit (Finance) has a $10,000 SIGN-ON BONUS. This role is responsible for the timely and quality delivery of a variety of complex areas across all lines of business, including Medi-Cal, Covered California, D-SNP, and PASC-SEIU. This position manages the financial audit team in ensuring the delegates such as plan partners, participating provider groups (PPGs), and capitated hospitals, Specialty Health Plans, and vendors contracted with L.A. Care adhere to contractual agreements, applicable laws & regulations, policies, and industry standards which provide medical, hospital, vision, dental, behavioral health, transportation and telehealth services. This position is responsible for planning, executing, reporting, and monitoring financial solvency audits and ensuring meeting the audit calendar and reporting requirements. This position manages the quarterly/annual financial analysis to ensure that delegates are financially solvent. The Manager monitors the plan partners' oversight activities of their Medi-Cal provider network. Manages all aspects of running an efficient and high-performance team, including hiring, supervising, coaching, training, annual performance reviews, disciplining, and motivating direct reports. Duties Manages all financial solvency related audits and related monitoring activities independently in accordance with general accepted auditing standards, generally accepted accounting principles (GAAP), regulations of the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and other federal and state guidelines. Responsible for the oversight of all aspects of financial solvency reviews including, but not limited to, the planning, execution, continuous monitoring, and reporting of annual financial audits, quarterly and annual financial analyses (ratio and trending analyses), and special projects. Manages staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Manages and ensures timely and accurate review of deliverables. Ensures financial solvency compliance with regulatory and contractual requirements for plan partners, PPGs, capitated hospitals, specialty health plans, and vendors. Manages the design, implementation, and reporting of special projects such as Medical Loss Ratio. Manages the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications. Manages the assessment, communication, implementation of regulatory requirements that may impact internal processes. Responsible for the on-going communication, collaboration, and issue resolution on financial solvency issues with interdepartmental personnel, key stakeholders, and delegates. Manages the formalization of key internal processes and monitoring tools with desktop procedures and applicable policies and procedures development. Responsible for the completion and review of financial audit team's pre-delegation assessment and delivery of monthly/quarterly request updates to various business units. Duties Continued Responsible for the overall communication and collaboration with cross-functional teams, senior leadership, and delegates. Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Oversees the monitoring and analysis of membership data by delegates on a monthly basis to assign the annual claim processing and financial solvency audits, adherence to regulatory requirements. Manages complex financial solvency audits to ensure quality deliverables, resolve audit issues, and issuance of final audit reports. Requests and follow-ups on Corrective Action Plans (CAPs) on non-compliant audit results. Develops, implements, and executes the audit program and audit procedures for updates and/or changes in the agreement and applicable regulations. Oversees and reviews the comprehensive financial analysis on a quarterly and annual basis to ensure Plan Partner (PPs), Participating Physician Groups (PPGs), and capitated hospitals, Specialty Health Plans, and vendors comply with the financial solvency requirements. Requests and follow-ups on CAP for non-compliant issues. Monitors the plan partners' audit and quarterly financial analysis of their Medi-Cal provider network. Communicates effectively with senior leadership on compliance matters from audits or quarterly financial statements analysis including recommendations and corrective action plans requirements. Maintains related company's policies and procedures ensuring they are current. Proactively identifies opportunities and solutions to improve the effectiveness and efficiency of the financial audit function. Performs other duties as assigned. Education Required Bachelor's Degree in Finance or Accounting or Related Field In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Master's Degree Experience Required: At least 6 years of experience in financial auditing in a managed care industry. At least 4 years of leading, supervising and/ or managing staff experience. Proven experience in leading and managing audit teams. Significant experience in assessing, investigating, and auditing compliance risks. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Demonstrated ability to handle the growing population in the L.A. Care network and audit activities. Excellent verbal and written communication, and presentation skills. Knowledge of relevant managed care regulations and audit methodologies. Excellent analytical and problem-solving skills. Ability to interface professionally with both internal and external customers at all levels of the organization. Must be self-motivated, detail-oriented, prioritize assignments, and able to work as part of a team. Knowledge of and ability to oversee the major responsibilities, accountabilities, and organization of the audit and compliance function. Knowledge of and ability to create, implement, evaluate and enhance internal control processes. Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint). Licenses/Certifications Required And/Or any of the following Licenses/ Certifications: Certified Public Accountant (CPA) Certified Internal Auditor (CIA) Certified Management Accountant (CMA) Certified Fraud Examiner (CFE) Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including * Paid Time Off (PTO) * Tuition Reimbursement * Retirement Plans * Medical, Dental and Vision * Wellness Program * Volunteer Time Off (VTO) Nearest Major Market: Los Angeles Job Segment: Accounting, CPA, Behavioral Health, Internal Audit, Medicaid, Finance, Healthcare Read Less

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  Deputy Chief Financial Officer  

  L.A. Care Health Plan

  - Los Angeles

  Posted: 02/06/2026

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  Salary Range: $297,088.00 (Min.) - $401,068.00 (Mid.) - $505,049.00 (M... Read More

  Salary Range: $297,088.00 (Min.) - $401,068.00 (Mid.) - $505,049.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Deputy Chief Financial Officer (Deputy CFO) serves as a strategic and operational finance executive responsible for driving financial performance, operational excellence and long-term financial sustainability for L.A. Care health plan. The Deputy CFO reports to the Chief Financial Officer (CFO) and serves as a key strategic partner to the CFO, the Finance Leadership team, and the Senior Leadership Team (SLT), providing executive leadership over Financial Planning & Analysis (FP&A), Procurement, and Medical Payment Systems and Services (MPSS). Moving beyond traditional financial reporting, the Deputy CFO drives forward-looking enterprise strategy through dynamic forecasting, comprehensive annual budgeting, cash management, financial performance metrics, business process improvement and strategic investment activities. Additionally, this role oversees the continued evolution of Procurement into a robust category management function. By ensuring the optimal allocation of capital and resources, the Deputy CFO drives financial alignment with L.A. Care's mission and long-term stewardship. The Deputy CFO is second in command and is responsible for providing leadership for cross-functional management in Finance Services. Duties Directs and elevates the FP&A function, leading the annual enterprise budgeting process, dynamic forecasting, and strategic capital allocation to support enterprise goals. Translates complex financial data into actionable insights for executive leadership and operational stakeholders. Directs all aspects of the treasury function. Ensure all investments are protected & in accordance with L.A. Care investment policies & in complete compliance with California Government. Oversees daily cash management and investment activities, optimizing liquidity and maximizing returns within the organization's approved risk frameworks. Provides executive oversight for Procurement, driving a strategic category management approach to vendor partnerships, sourcing, and enterprise-wide spend optimization. Directs the MPSS function, ensuring operational excellence, efficient resource utilization, and alignment with overarching organizational objectives. Partners with the CFO and SLT to shape financial strategy, translating complex data into actionable, forward-looking business insights for all operating segments and product lines. Supports the CFO in preparing and presenting enterprise-wide financial models, projections, investment strategies, and operational initiatives to the Board of Governors and the SLT. In collaboration with the CFO, the Deputy CFO represents L.A. Care in California Department of Health Care Services (DHCS) workgroup meetings as assigned. Works with other Local Initiatives and County Organized Health Plans on applicable legislative and/or industry issues. Evaluates the financial impact of DHCS rate developments and legislative changes, integrating these variables into long-term financial forecasts and enterprise planning. Maintains collaborative relationships with regulatory agencies and governmental entities to support compliance, reporting obligations, and enterprise readiness. Cultivates a high-performing culture by managing departmental structures, optimizing spans to ensure the right number of direct reports for effective leadership, and championing staff development. Navigates a highly matrixed organization to build strong, collaborative relationships with internal departments, external stakeholders, and regulatory bodies. Assesses the financial implications of state and federal reimbursement changes, including major healthcare rate developments, and incorporates them into long-range financial forecasting. Partners with the CFO prepare and deliver reports, briefings, and strategic recommendations to the Board, senior leadership teams and governance committees. Provides overall strategic support for Finance Services and performs other duties as assigned. Education Required Bachelor's Degree in Finance or Related Field In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Master's Degree in Business Administration or Related Field Experience Required: At least 10 years of experience in high level financial management. At least 10 years of supervisory/management experience. Must be an experienced manager of people and relish taking on and achieving success on challenging work in a complex company structure. Experience with outside regulators, governmental entities, etc. Prior experience working with government and other regulatory-like agencies. Preferred: Experience with Medi-Cal, Medicare Advantage, Covered CA, or Medicaid Managed care. Experience supporting Board committees and executive governance structures. Skills Required: Strong organizational leadership, administration, analytical, negotiation and financial management skills. Strong leadership skills and the ability to build effective working relationships internally and externally. Excellent communication skills, negotiating skills, consensus building, analytic ability, planning and implementation skills. Ability to work effectively within a matrix environment, influencing and leading others without a direct reporting relationship. Licenses/Certifications Preferred Certified Public Accountant (CPA) Physical Requirements Light Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including * Paid Time Off (PTO) * Tuition Reimbursement * Retirement Plans * Medical, Dental and Vision * Wellness Program * Volunteer Time Off (VTO) Nearest Major Market: Los Angeles Job Segment: Accounting, CPA, Financial, Medicaid, Medicare, Finance, Healthcare Read Less

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  Appeals and Grievances Nurse Specialist RN II  

  L.A. Care Health Plan

  - Los Angeles

  Posted: 01/06/2026

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  Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Ma... Read More

  Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to members with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS) Medi-Cal/Medicare, or commercial insurance. Duties Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department. Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements. Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours. Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation. Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE). Process the case thru to effectuation and final case documentation in the A&G system of record. Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE). Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director. When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps. In instances where necessary, sends written notifications to appropriate parties. All interactions including verbal outreach and written communication will be documented in the A&G system of record. Participates inter-rater reliability training and assessments. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical RN. At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment. Skills Required: Excellent interpersonal and communication skills. Computer literacy and adaptability to computer learning. Time management and priority setting skills. Must be organized and a team player Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. Good working knowledge of regulatory requirements/standards. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call. This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including * Paid Time Off (PTO) * Tuition Reimbursement * Retirement Plans * Medical, Dental and Vision * Wellness Program * Volunteer Time Off (VTO) Nearest Major Market: Los Angeles Job Segment: Nursing, Registered Nurse, Medicare, Medicaid, Pharmacy, Healthcare Read Less

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