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October 5, 2015 | VOLUME 22 | NUMBER 38

T O P S T O R I E S

Kaiser Adopts More Stringent Rules for Flu VaccinationsMask policy for unvaccinated workers effective Oct. 1

Kaiser Permanente reached an agreement with a coalition of unions to adopt a policy requiring employees who don’t receive a flu vaccine to wear a surgi-cal mask at work.

The new policy makes Kaiser Permanente the latest health system or local health agency in California to adopt stricter influenza vaccine regulations that require employees to wear a surgical mask on the job throughout the flu season if they choose not to be vaccinated for the flu. The new policy went into effect Oct. 1.

“In this landmark contract, we have reached an agreement on a national policy of frontline caregivers protecting themselves, their families, and our mem-bers from the flu by receiving a flu shot,” said Dennis Dabney, senior vice presi-dent, National Labor Relations and Office of the Labor Management Partnership at Kaiser Permanente.

The coalition that negotiated the agreement includes the Service Employees International Union and the American Federation of State, County, and Municipal Employees. The coalition represents approximately 81,000 Kaiser Permanente workers in California and about 24,000 employees in six other states and Washington. DC.

The California Hospital Association (CHA) did not comment specifically on the new Kaiser policy but said it supports policies that help reduce the risk of hospital patients being exposed to influenza during a hospital stay.

“We believe all healthcare workers should be vaccinated for influenza and we support policies that advance that goal,” said Jan Emerson-Shea, vice presi-dent of external affairs for the CHA. “We believe healthcare workers have a moral responsibility to do this for their patients.”

According to the California Department of Public Health (CDPH), the rate of healthcare personnel at hospitals who receive flu vaccines has increased since 2010 as more health systems and county health departments adopt surgical mask policies for workers who won’t be vaccinated. For the 2013-2014 influenza season, the latest figures available, CDPH reported that 81% of healthcare person-

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Kaiser Adopts cont.» Santa Clara County officialshave filed a lawsuit against TurnerConstruction over a project to build anew hospital building for Santa ClaraCounty Medical Center. According to areport from NBC Bay Area News, SantaClara County executive Jeff Smith saiddelays in construction of the 168-bedbuilding, which was originally sched-uled to open Sept. 19, are now costingthe county more than $100,000 perday in lost revenue. “We’ve asked themfor remedies to these situations andthey’ve never been able to give us atrue remedy,” said Smith. “They’ve justgiven us excuses.” The lawsuit is seek-ing tens of millions of dollars in dam-ages for delays that county officials sayhave set the project back two years.Turner Construction officials allege thecounty is to blame for delays because ofrepeated requests to change the build-ing’s design. Santa Clara County termi-nated its contract for the $300 millionproject with Turner Construction lastmonth.

» A replacement hospital for FrankR. Howard Memorial Hospital inWillits is scheduled to open in mid-October. According to a report in theNorth Bay Business Journal, the $64million facility covers 74,000 squarefeet and features 25 private patientrooms along with an emergency depart-ment and a helicopter pad. “The jour-ney was not without its challenges,but through everyone’s hard work, weare at the final lap in our race,” saidRick Bockmann, president and CEOof the hospital. “Once we secure our

nel at California hospitals received flu vaccines. That compares to just 64.3% in 2010-2011, 67.8% in 2011-2012, and 74% in 2012-2013.

A 2015 CDPH report states that during the 2013-2014 flu season, 23 counties and local health jurisdictions in the state had policies in place that require employees to either receive a flu vaccine or wear a mask, an increase from 16 counties in 2012-2013. The list includes Los Angeles, San Diego, Fresno, San Joaquin, Contra Costa, and Alameda counties.

CDPH data also showed that 85% of acute care hospitals in the state achieved healthcare personnel vaccination rates of 60% or higher in 2013-2014 and that 18% of hospitals reported rates of 90% or higher. That compares to 71% of hospitals reporting rates of 60% or higher in 2012-2013 and 13% of hospitals reporting rates of 90% or higher. The CDPH has established a goal of having 90% of all healthcare personnel vaccinated for the flu by 2020.

San Diego County adopted its mask policy for the 2014-2015 flu season. Wilma Wooten, MD, public health officer for San Diego County, said most health-care providers in the county were receptive to the policy requiring healthcare per-sonnel to wear masks if they decline a flu shot.

“Most providers were very supportive,” said Wooten. “And all the data we looked at shows that these types of polices increase vaccination rates.”

Wooten said anecdotal evidence indicates many healthcare workers who initially declined the vaccine and opted to wear a mask during the last flu season eventually changed their minds. “I think some employees get tired of wearing a surgical mask or having patients ask them why they’re wearing the mask,” said Wooten. “So it appears to be effective.” —DOUG DESJARDINS

Study Finds Other States Have Issues with Provider DirectoriesInaccurate health plan listings similar to California’s

A new study of health plan provider directories in four states found that most have problems with errors and outdated information similar to those in some Covered California directories.

The California HealthCare Foundation study titled Directory Assistance: Maintaining Reliable Provider Directories for Health Plan Shoppers, examined the problems state officials in Colorado, New York, Maryland, and Oregon experienced with provider directories and the steps they took to address their problems.

Amy Adams, senior program officer for CHCF, said the study shows California is not the only state that’s experienced problems in creating and main-

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license from the CDPH [California Department of Public Health] we hope to officially open our doors in the mid-dle of October.” The hospital is part of Adventist Health.

» The number of overweight andobese children in Southern Californiais declining, according to a study pub-lished in the Journal of Pediatrics. Thestudy tracked the body mass index of1.3 million Kaiser Permanente HMOmembers between the ages of 2 and 19from 2008 to 2013. The study foundthat obesity rates in the study popula-tion declined 1.6%, from 19.1% in 2008to 17.5% in 2013. During that same timeperiod, the rate of overweight childrendecreased 2.2%. Though the overalldecrease in rates of obese and over-weight children was small, the studycited it as “statistically significant” andsaid it indicates that trends are “head-ing in the right direction.”

» The California Nurses Association(CNA) has withdrawn its request fora new election to unionize nurses atSutter Memorial Medical Center inModesto. According to report in theSacramento Business Journal, CNA fileda petition to hold an election in 2014but nurses voted 462-352 against join-ing the union. After the election, CNAfiled a complaint with the NationalLabor Relations Board and the boardrecommended that the hospital andCNA hold a new election. CNA spokes-person David Johnson said the union inSeptember withdrew its request for asecond election but that it plans to file a

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taining provider directories for health plans purchased on state health insurance exchanges. “The study showed many instances where other states were struggling with the same problems California has struggled with,” said Adams.

The study noted that “directory errors often lead to a consumer seeking care at the wrong address, or worse, a consumer may learn that the health insur-ance product they purchased does not cover a specific provider they want to see.”

According to the study, state officials in New York penalized health plans for directory errors and ordered some to “pay restitution to consumers who paid more than they should have because they saw providers erroneously listed as in-network.” The study noted that “those actions created an environment that moti-vated carriers to take steps to ensure that their provider directories are up-to-date and accurate.”

In Maryland, the study noted that a “secret shopper” study of provider directories for the Maryland Health Connection exchange found that only 14% of psychiatrists listed in directories were accepting new patients and that 57% of psychiatrists listed were “unreachable.” A 2014 study conducted by the California Department of Managed Health Care found that 13% of physicians listed as in-network for one health plan were not accepting patients for that plan and that 18.2% of physicians listed in another directory were not at their listed address.

In January, Sen. Ed Hernandez (D-West Covina) introduced Senate Bill 137, which would create new standards for provider directories and require health plans to update directories on a weekly basis. That requirement goes beyond man-dates in Colorado and Maryland—where directories must be updated once every other week—and Washington, which requires monthly updates.

The bill would also require that directories indicate whether providers are currently accepting new patients and list languages other than English that the physician or staff members speak. AB 137 was approved by state legislators in August but still needs to be signed by Gov. Jerry Brown before it becomes law. The California Association of Health Plans has not taken a position for or against the bill, which would go into effect in July 2016.

The California Association of Physician Groups (CAPG) said it sup-ports the study’s recommendation to establish a single electronic portal for updating directories. “This system would enable busy physicians to more easily update their status and provide up-to-date information…” said CAPG president and CEO Donald Crane.

Adams said SB 137 is a “good first step” to correcting problems with directories. “For the most part, the federal government said health plans needed to create provider directories but didn’t provide much in the way of guidance,” said Adams. “So bills like SB 137 are establishing a process for health plans to create and maintain provider directories.” —DOUG DESJARDINS


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new request soon. Johnson said “timing is very important” and that “we’ll orga-nize around our own time, not the labor board’s time.” In a statement, Sutter Memorial Medical Center CEO Daryn Kumar said that “Memorial Medical Center RNs remain union free” and that “we feel this represents the wishes of a majority of our nurses.”

» Regional Medical Center of San Jose and Good Samaritan Hospital in San Jose received the Gold Seal of Approval for Sepsis Certification from The Joint Commission. Both hos-pitals were evaluated through onsite reviews by Joint Commission analysts to ensure compliance with national sep-sis care standards and clinical practice guidelines. “Regional Medical Center and Good Samaritan Hospital have thoroughly demonstrated a high level of care for patients with sepsis,” said Wendi J. Roberts, RN, executive direc-tor of Certification Programs for The Joint Commission. “We commend these two organizations for becoming a lead-er in sepsis care.”

» More than 2,000 people attended a free, two-day health clinic called Care 4 a Healthy IE in San Bernardino hosted by Molina Healthcare and the Tzu Chi Medical Foundation. The clinic held Aug. 15-16 at the National Orange Show Events Center provided free medical, dental, and vision services for Inland Empire residents. “We are happy to continue to provide access to healthcare services for those who need it most,” said Richard Chambers, presi-

Opponents of Mandatory Vaccine Bill Submit Signatures for Referendum Initiative would repeal Senate Bill 277 if successful

Opponents of a bill that would eliminate personal belief exemptions for child-hood vaccines in California are awaiting the results of a signature-gathering effort to repeal the law and put the issue before state voters as a 2016 ballot measure.

Opponents of Senate Bill 277 submitted signatures gathered during a three-month effort to county clerks on Sept. 28 and will need 365,000 valid signa-tures of registered state voters for the referendum to quality as a ballot measure. Former state assembly member Tim Donnelly (R-Twin Peaks), who led the SB 277 Referendum, had no estimate on the total number of signatures gathered but alleged in a statement that signature-gathers were harassed and that the referen-dum was “sabotaged from without and within.” County clerks have until Oct. 28 to count the signatures submitted.

SB 277 was approved by state legislators and signed by Gov. Jerry Brown in June. The bill would require all parents to show proof their children have been vaccinated for childhood diseases such as measles and whooping cough before enrolling in school. SB 277 will also eliminate an exemption that allowed parents to opt out of having children vaccinated because of personal beliefs. The California Department of Public Health reported that 2.5% of parents in California signed personal belief exemptions in 2014.

SB 277 was authored by Sens. Richard Pan (D-Sacramento) and Ben Allen (D-Redondo Beach). At a Sept. 28 press conference, Pan said he expects the results of the referendum to show that state residents support SB 277.

“I’m sure the voters of California are not interested in letting a privileged few take away the rights of all Californians to be safe from preventable diseases,” said Pan. “If they [SB 277 Referendum] don’t have the signatures, I think it would be a direct reflection of the fact that Californians want to see their communities safe.” The bill is scheduled to go into effect on July 1, 2016.

Opponents of SB 277 contend that childhood vaccines can be danger-ous and some suggest they can cause autism. Pan said that there is “no reputable science” to support those claims and said studies that suggested a link between autism and vaccines have since been discredited.

The bill was submitted by Pan and Allen following a measles outbreak that sickened 137 California residents in late 2014 and early 2015. The majority of people affected by the outbreak were not vaccinated for measles. Supporters of SB 277 also cited whooping cough outbreaks in 2010 and 2014 that collectively affected more than 18,000 state residents. —DOUG DESJARDINS

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E V E N T S

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Oct. 15. OMSS Annual Assembly and Education Conference. Disneyland Hotel. Anaheim. A one-day educational confer-ence for physicians and medical profes-sionals. Sponsored by the California Medical Association’s Organized Medical Staff Section. To register, please visit http://www.cmanet .org/events/detail/?event=omss-annual-assembly-and-education-conference2

Oct. 19-21. CAHP 30th Annual Conference. JW Marriott Desert Springs Resort & Spa. Palm Springs. A three-day conference focused on how health plans in California are dealing with change. Sponsored by the California Association of Health Plans. To register, please visit http://www.calhealthplans.org/con-ferences.html

Oct. 29. IMQ 2015 Medical Staff Conference. Embassy Suites, Los Angeles Airport. A one-day conference for medi-cal professionals focused on the essentials for leading a medical staff. Sponsored by the Institute for Medical Quality. To regis-ter, please visit http://www.cmanet.org/events/detail/?event=imq-2015-medi-cal-staff-conference

Nov. 15-18. CAHF 65th Annual Convention & Expo. Renaissance Palm Springs and Palm Springs Convention Center. A gathering of healthcare profes-sionals focused on new technologies and trends in long-term care. To register, please visit http://www.cahfconvention.com/

dent of Molina Healthcare of California. “Care 4 a Healthy IE goes beyond a weekend of free services. It’s an event where we identify health conditions for the first time and refer patients for follow-up care so that over time, we can improve the health of our communities.” Tzu Chi provided free dental cleanings, checkups, and extractions.

» The Hospital Quality Institute (HQI) in Sacramento has been selected to par-ticipate in phase two of the Hospital Engagement Networks’ (HEN) Partnership for Patients initiative. The program will recruit more than 100 hospitals and health systems in California to take part in a national initiative to reduce the incidence of hospital-acquired infections and preventable hospital readmission. Phase 1 of the project involved 147 California hospitals and produced a 65% reduction in early elec-tive surgeries and a 58% reduction in pressure ulcers. “In the next phase of HENs, HQI will continue building on the strong work of our hospital partners to continuous-ly improve quality of care and expand the use of best practices,” said HQI president Julianne Morath. HQI is an affiliate of the California Hospital Association and three regional hospital associations in California.

» L.A. Care Health Plan will receive up to $15.8 million in federal funding over a four-year period to help physicians in Los Angeles County improve quality of care and increase access to care for patients. L.A. Care is one of 39 healthcare orga-nizations in the U.S. receiving grants through the federal Transforming Clinical Practices Initiative. “Supporting doctors and other healthcare professionals to change the way they work is critical to improving quality and spending our health-care dollars more wisely,” said U.S. Health & Human Services Secretary Sylvia M. Burwell in a statement. The funding will help more than 3,100 providers in Los Angeles County launch or expand improvement projects.

» Gov. Jerry Brown signed a bill that will allow licensed midwives to provide more comprehensive care for Medi-Cal patients. According to a report in the San Francisco Business Times, Senate Bill 407 authored by Sen. Mike Morell (R-Rancho Cucamonga) will allow licensed midwives to serve as providers in Medi-Cal’s Comprehensive Perinatal Services Program. Current state law allows midwives to practice without physician supervision when ordering medical supplies and devices and administering diagnostic tests. The bill was sponsored by the California Association of Midwives (CAM). Sarah Davis, legislative and policy chair for CAM, said the bill will ensure that “California families of all income levels will have increased access to licensed midwives.”

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

MEDICARE RISK ADJUSTMENT DIRECTORResponsible for leading the enterprise Risk Adjustment program and ensuring that risk exposures and opportunities are identified with the key objective of optimizing revenue integrity and accuracy. This posi-tion also has responsibility for retrospective and prospective strategies and the internal Risk Adjustment team, and works with the prospec-tive team to drive enhanced physician engagement and member inter-action. The Medicare Risk Adjustment Director will have accountability to the senior management leaders of HPSM.

Accountable for the operating result and ultimate outcome of Risk Adjustment program and provides strategic direction for a high functioning risk adjustment team responsible for all risk adjustment plan execution. Provide leadership and guidance for overall Risk Adjustment programs as well as identifying and application of best practices to ensure efficacy and accuracy of risk adjustment programs. Develop and regularly update risk adjustment policies and procedures. Facilitate relationships of the cross-functional and integrated process across the organization and with key segment leaders to develop pro-grams and streamline and leverage risk adjustment related activities including prospective services (member and provider engagement, and in-home/supplemental assessments) and retrospective activities. Provide reporting and analysis of revenue results to assist product development strategy and bid support. Model and monitor risk adjust-ed revenue by line of business and review cost and utilization trends to understand impact on revenue. Drive the preparation of analysis and reporting of ongoing revenue trends across multiple product lines and provide ongoing revenue variance reporting and mitigation planning. Develop strategic plans by determining goals, metrics, timeframes and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives. Oversee risk adjustment related activities and compliance, including but not limited to HCC programs, Risk Adjustment Data Validation (RADV), enroll-ment, and special status and encounter data to ensure achievement of accurate, timely, and expected outcomes. Oversee and manage external vendor relationships, including audits, for performance and compliance.

Education and Experience Equivalent to: Bachelor’s Degree in Business Administration, Finance, Health Care Management, or related field, required. Master’s Degree or above is preferred but not required. Five (5) years in a managed care setting with at least three (3) years in a risk adjustment leadership type role. Prior management experi-ence of at least two (2) years in a supervisory role, especially in leading teams, required.

CARE COORDINATION UNIT MANAGERManage and provide clinical oversight of the Care Coordination Unit. This includes staffing, supervision, and oversight of clinical and sup-port staff. Areas of responsibility include external, collaborative, and primary care coordination. Report to the Deputy Chief Medical Officer.

Education and Experience Equivalent to: Bachelor’s degree in nurs-ing, pharmacy, social work, or other healthcare related field; a Master’s degree is preferred. Three (3) years of management experience in a health care and/or managed care field. Experience with Medicare-SNP programs preferred.

Licensure and Certification: Valid California license as a Registered Nurse or Licensed Clinical Social Worker

CARE COORDINATION CASE MANAGERPerform comprehensive assessments, develop individualized care plan-ning, initiate and coordinate case conferences with providers of ser-vices, make determinations regarding appropriateness of services and determine medical necessity of services requiring prior authorization. Additionally, identify and coordinate the short and/or long term needs of catastrophically/chronically ill and/or injured persons and their families. Coordinate clinical needs across the continuum of care by con-tacting and establishing links with physicians and other providers and community resources.

Education and Experience Equivalent to: Bachelor’s degree in nurs-ing or a related health or social services field. Two (2) years clinical nursing experience. Employment in the geriatric nursing field.

Licensure and Certification: Valid California license as a Registered Nurse. PHN preferred. Certified Care Manager (CCM) preferred.

PROVIDER NETWORK SUPPORT ANALYSTEvaluate contracted providers, organizations, and companies through the design and development of reports and the analysis and interpreta-tion of data. This includes the development of data validation tools and reports to facilitate the oversight of vendors, as well as the selection of actionable changes in business processes and systems to achieve the operating and business goals of the Provider Services Department and HPSM overall.

Education and Experience Equivalent to: Bachelor’s degree in Statistics, Mathematics, Business, Economics, or related field. Two (2) years of business analysis experience, preferably in the health care environment.

BENEFITS INFORMATION: Excellent benefits package offered including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for com-pensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

APPLICATION PROCESS: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 701 Gateway Blvd., Suite 400, South San Francisco, CA 94080. or via Email: [email protected] or via Fax: (650) 616-8039 File by: Continuous until filled. EOE

Please visit our Careers page at http://www.hpsm.org/abouthpsm/employment-opportunities.aspx





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

• Sr. EDI Programmer Analyst• Manager, SFHP Service Center• Sr. Business Analyst, Business

Intelligence• Quality Assurance Analyst• Business Solutions Analyst• Finance Department Support

Specialist• Clinical Quality Coordinator

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

All qualified candidates must submit an online application. Online applications and full

job descriptions can be found at: http://www.goldcoasthealthplan.org/about-us/careers.aspx

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

√ Manager of Quality Improvement

√ Clinical Operations Assistant

√ Care Management, RN

√ Administrative Analyst

√ Director of Information Technology

√ Health Navigator Lead

Medicare STARS AnalystInter Valley Health Plan is a not-for-profit, Medicare Advantage health plan providing health insurance products for more than 23,000 Medicare members throughout Los Angeles, Riverside, San Bernardino and Orange Counties. It is comprised of active leaders in today’s health care arena and is committed to continually devel-oping innovative, “best practice” approaches to coordinated health care in order to better meet the needs of its members. Inter Valley Health Plan is headquartered in Pomona, California.

The Medicare STARS Analyst will primarily provide informatics support in the areas of HEDIS, CAHPS, HOS and other analysis and reporting related to Medicare STARS.

Major Accountabilities• Provide analysis of HEDIS, CAHPS, HOS and other STARS

reporting metrics• Develop executive summaries to report on plan status and

progress in improving STARS measures• Analyze and identify trends and potential barriers to

achieving targeted outcomes• Develop solution-based, user friendly initiatives to support

practice success• Assist in development of training and analytical materials for

HEDIS, CAHPS, HOS and other STARS improvement activities

Candidate Required Qualifications:Applicants need to meet the qualifications listed to be considered for this position.

• Bachelor’s degree in Health Care Administration, Public Health, Economics, or Statistics

• At least 3 years of experience with analyzing HEDIS, CAHPS, HOS or STARS data

• Strong knowledge of the Medicare market, products and competitors

• Knowledge of statistical concepts and Medicare STARS cal-culations preferred

• Analytic skills for solving multi-dimensional problems• Proficiency in MS Access, Excel, and relational databases;

Basic knowledge of SQL preferred• Adept at concurrently manage multiple projects in a

demanding, fast-paced work environment• Ability to work independently and within a team environment• Effective verbal and written communication skills

Please submit your resume with cover letter to:

[email protected]

.





Kern Health Systems mission is dedicated to improving the health status of our members through an integrated managed health care delivery system. We are looking for enthusiastic, energetic and dedicated health care professionals to join our fast growing team! If you want to build a career in an organi-zation that is dedicated to our community and the people that live here… then come meet the challenge by making us your first career choice!

Immediate Openings:

• Disease Management Case ManagerRegistered Nurse

• Clinical Intake Coordinator Registered Nurse I

• UM Registered Nurse Facility Based

• UM Case Manager Registered Nurse

• Medical Director

Compensation is based on experience, education and qualifications. For a complete position description on these exciting career oppor-tunities, please visit our career center at kernhealthsystems.com or

email resume to: [email protected]. E.O.E

AHPN is a California medical foundation affiliated with Adventist Health that operates 17 clinics located throughout Southern California. AHPN partners with more than 100 physicians and advance practice practitioners to provide services ranging from Family Practice, Pediatrics and Internal Medicine to Cardiology, Neurology and General Surgery. Positions are located in the greater Los Angeles area.

DIRECTOR OF CLINIC OPERATIONSResponsible for directing and supervising assigned clinic locations. The accountability of this position is to ensure high quality health care is deliv-ered while maintaining a reasonable cost structure.

Duties & Responsibilities

Demonstrates strong leadership skills, leads by example and assures all employees promote AHPS’s values. Reviews patient scheduling to ensure community needs are met. Oversees financial performance of assigned clin-ics. Develops annual budget in conjunction with the Regional VP. Monitors and reports on monthly performance against the budget. Manages staff in a supportive and professional manner, as well as completes employee per-formance reviews. Oversees recruiting, interviewing, hiring, and disciplinary process for staff. With support of leadership, is responsible for provider rela-tions, performance and ongoing success. Ensures successful implementation and adoption of EMR systems.

Education and Experience

Bachelor’s Degree from a 4-year college or university. Minimum of 5 years of leadership experience in an outpatient multi-clinic setting required.

PRACTICE ADMINISTRATORManages the daily operations of the medical practice including personnel, financial, clerical, housekeeping, and maintenance and purchasing functions. Plans programs, allocates, and assigns duties to employees. Reviews medi-cal records for compliance and billing requirements. Monitors activities and operations to ensure that the practice successfully meets its objectives.

Duties & Responsibilities

Manages all staffing needs. Responsible for staff schedule, including cover-age of breaks and time off. Conducts performance reviews, promotions and disciplinary action. Responsible for maintaining high moral and good rela-tions throughout the office. Maintains office policies and procedures. Directs operations to prepare and retain files according to government standards, and carries out managed care audit requirements. Completes credentialing applications for providers. Responsible for Profit & Loss for the office. Audits billing data and inventory.

Education and Experience:

Bachelor’s Degree from a 4-year college or university. Minimum of 3-5 years of experience managing an outpatient clinic.

Please submit your resume to [email protected]

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Cedars-Sinai is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace. EEO/AA/F/Veteran/Disabled

Exceptionally developed skills, a dedication to excellence and a desire to transcend the ordinary. This is the source of true art. It is also the foundation for the world-class healthcare provided at Cedars-Sinai. Our people bring an unmatched passion to their craft and it shows in everything they accomplish. If you want to be your best, you owe it to yourself to work with the best. You’ll have that opportunity when you work at Cedars-Sinai Medical Network.

Physician Network Development Manager Beverly Hills, CA

This position will take on a lead role in building Cedars-Sinai’s HMO provider network in strategic markets poised to accept HMO, PPO and Medicare patients. Involves partnering with the Director of Network Development to build a high quality, integrated delivery network while focusing on developing relationships with and recruitment of PCPs, specialists and ancillary providers. The successful candidate will have the expertise required to research/maintain market intelligence on the managed care provider landscape, analyze complex business problems and identify optimal solutions. Requires a BA/BS degree with 5+ years of healthcare industry experience, preferably within a managed care setting. MS degree in Public Health or Health Services Administration preferred.

In addition to professional development opportunities, Cedars-Sinai offers a competitive compensation and benefits package. For more information or to apply, visit us online at: https://www.cedars-sinaimedicalcenter.apply2jobs.com/ and reference Req #M10579.

cedars-sinai.edu/careers

http://www.cedars-sinai.edu/Careers/

http://www.kernfamilyhealthcare.com/





Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. We serve over 1,000,000 members in Riverside and San Bernardino counties in Medi-Cal,Cal MediConnect Plan, 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!

FINANCIAL ANALYSTBachelor’s degree required. Minimum three(3) years of Finance experience. Experience and knowledge of complicated budgets preparation and budget to actual analysis in Excel. Experience in Managed Care preferred.

Strong knowledge and demonstrative proficiency utilizing Microsoft Applications (Word, Excel, Access & PowerPoint). Strong understanding of accounting and financial principles and methodologies and attention to detail. Experience with Oracle or Hyperion a plus. Principles and practices of health care industry and strategies, health care systems, and budget modeling and forecasting.

CLAIMS QUALITY AUDITING & TRAINING MANAGERBachelor’s degree preferred. Education requirement may be waived if candidate has extensive supervisory and operational experience in a medical claims payer environment. Five (5) years of medical claim operations experience with at least three (3) years in a related supervisory capacity. Compliance audit experience preferred. Extensive experience writing policies & procedures and training documentation. Highly organized with the ability to balance multiple projects and meet deadlines. Strong presentation skills. Ability to transform concepts into business operations. Experience in a Lean strategy environment highly desired.

Solid understanding of Medi-Cal and Medicare rules and regulations governing claims adjudication practices and procedures preferred. Demonstrated business training principles and techniques. Analytical skills with emphasis on time management, quality statistics, and problem solving. Strong writing, organizational, project management, presentation and communication skills required. Must have a high degree of patience, excellent interpersonal/communication skills.

CLAIMS QUALITY AUDITING SPECIALISTPossession of a High School diploma or equivalent. Two (2) years experience in examining and processing medical claims; Medicare/Medi-Cal experience.

Responsible for ensuring the integrity of all data created and updated by the Claims Processing staff. The QA Specialist will utilize Cost Management tools, identify training needs, and define effective and efficient methods for accurate data entry and adjudication. Review and assess data reports and audit Claims Processor output to confirm payment accuracy and completeness of data entry. Experience with Microsoft applications preferred. ICD-9 and CPT coding and general practices of claims processing. Professional demeanor, excellent communication and interpersonal skills, strong organizational skills. Prefer knowledge of capitated managed care environment.

MEDICARE CLAIMS SUPERVISORPossession of a bachelor’s degree or equivalent work experience in a Managed Care or Health Care environment. Four (4) to six (6) years experience in a managed care environment in the areas of claims processing, and or provider payment appeals and disputes, with at least one (1) year in a supervisory capacity. A thorough understanding of claims industry and customer service standards. Prior Medicare experience preferred.

Extensive knowledge of ICD9, CPT and Revenue Codes. Solid understanding of the CMS and DHCS claim regulations, including AB1455. Principles and techniques of supervision and training. Analytical skills with emphasis on time management, database maintenance, spreadsheet manipulation, and problem solving. Strong writing, organizational, project management, and communication skills proficiency required. Must have a high degree of patience, excellent interpersonal and communication skills.

DIRECTOR PROCESS IMPROVEMENTPossession of a Bachelor’s degree from an accredited four (4) institution required, preferably with an emphasis in a Technical Science or Engineering. Masters degree in Public or Business Administration preferred. Certified Professional in Healthcare Quality preferred. Certified Lean Six Sigma Black Belt or Master Black Belt preferred. Minimum of ten (10) years performance management and quality improvement experience with an emphasis on Lean/Six Sigma methodologies required. Proven skills adapting and applying Lean Six Sigma methodologies, performance management and quality improvement in a public health setting. Demonstrated understanding of business principles, strategy, technology processes and operations with an inherent ability to apply technology in solving business problems. Strong leadership, communication, written and interpersonal skills to execute and manage activities in a fast paced environment. Ability to establish and maintain effective working relationships at all levels within the organization.

Ability to exercise discretion and independent judgment, make decisions and must possess strong analytical skills. Ability to influence management and create positive change, as well as gather data, perform analysis, recommend courses of action for greater productivity independently. Must have ability to perform research and analysis in support of company inquiries and modify and enhance the modeling effort to accommodate new processes, procedures, products and services. Position requires an individual who is extremely organized with excellent written and verbal communication skills and ability to establish and maintain effective working relationships. Must have the ability to model concepts and to access and manipulate data through self-system access and personal analysis.

Please apply on-line: https://ww3.iehp.org/en/about-iehp/careers/

INLAND EMPIRE HEALTH PLAN Rancho Cucamonga, CA

Please visit our website at www.iehp.org






ELIGIBILITY PHARMACY ANALYSTBachelor’s degree required, Pharmacy Technician License preferred. Three (3) years experience in a health plan or PBM (Help Desk). Claims adjudication experience preferred. Project Management & Audit experience required. Experience with file management and working with different file formats (e.g. text files). Experience with analyzing and trending eligibility/claims data.

Expert on Medicare Part D benefits, rules and regulations. PDE knowledge of error resolution, and calculations. Must have excellent grammar and writing skill sets. Excellent verbal and communication in conference calls and in large meetings required. Advanced skills in Microsoft Applications (Word, Excel, Access, SQL & PowerPoint). Ability to multi-task in a fast pace environment. Ability to prioritize workload and meet deadlines. Self starter who can take the lead on project and manage its progress for completion. Occasional travel for conferences and onsite training with PMB vendor.

QUALITY ASSURANCE NURSE RN/LVN – COMPLIANCEPossession of a bachelor’s degree at an accredited four (4) year institution preferred. Possession of a RN/LVN California License. Three (3) or more years of demonstrated experience in an office environment, at a professional level, preferably in a Compliance function. Two (2) years experience in a managed care environment.

Demonstrated proficiency in Microsoft Office products (Word, Excel, PowerPoint, Outlook, etc.). Excellent interpersonal and communication skills, strong organization skills, ability to establish and maintain effective working relationships both within and outside of the organization. A wide degree of creativity and latitude is expected.

REPORTING ANALYST – COMPLIANCEPossession of a high school diploma or equivalent. Bachelor’s degree preferred. Five (5) years experience required in an office environment.

The Reporting Analyst will be responsible for providing support to the Compliance Department by developing, tracking, manipulating and monitoring reporting activities including working with the appropriate departments for regulatory reporting. Strong organizational skills and attention to detail. Proficient knowledge of Microsoft Access, Word and Excel required. Project Management experience preferred.

NURSING INFORMATICS MANAGERMaster’s Degree or PhD in Nursing or related clinical field, with experience in statistics and an emphasis on quantitative analysis

required. Health informatics certificate preferred. 2+ years of clinical data analysis experience in the healthcare industry or medical research area.

This position reports to the Director of Medical Operations, knowledge of healthcare data (preferably managed care / health plan data) required, including but not limited to membership, eligibility, claims, encounters, pharmacy, provider, and financial data. Knowledge of CMS Star Rating methodology, HEDIS measures, and HCC risk adjustment methodology preferred. Advanced skills in Microsoft Office, SQL, and Access required. Strong analytical and critical thinking skills required. Excellent technical, interpersonal, written and oral communication skills required. Experience with data mining tools preferred.

RISK ADJUSTMENT INFORMATICS MANAGERBachelor’s degree in a health-related field required, Master’s preferred. Will accept five (5) years related work experience in lieu of education requirement. AHIMA or AAPC Certified Coder preferred. Possession of a valid California Drivers license and valid auto insurance. Four (4) or more years experience in Medicare Managed Care Plan Reporting, Medicare (RAPS/HCC Informatics at a Health Plan. Strong data analysis experience, specifically in the areas of risk adjustment.

AHIMA or AAPC Certified Coder with experience in managed care, program/project management, data analysis and interpretation. Working knowledge of Medicare RAPS/HCC programs and CMS HCC coding requirements for Medicare Advantage and Part D plans. Excellent written and verbal communication and interpersonal skills, ability to establish and maintain effective working relationships with others, strong critical thinking skills required, ability to demonstrate sound analytical reasoning.

HCC CODING SPECIALISTAHIMA or AAPC Certified Coder (CPC license). RN or LVN issued by the State of California required. Two (2) years experience in HCC Coding in an HMO setting is preferred. Must have strong chart audit experience in HCC Coding.

Experience in managed care, program/project management, data analysis and interpretation. Working knowledge of Center for Medicare & Medicaid Services (CMS) HCC coding requirements, ICD-9 and CPT guidelines are required. Knowledge in HCC-Risk Adjustment process and health insurance concepts as they relate to Medicare Advantage and Part D plans is required. ICD-10 coding certification preferred. Ability to take general direction and manage complex projects within deadlines. Excellent written, oral, and presentation skills. Proficiency in Microsoft Word, Excel, and other computer applications. Valid State of California license and insurance.









ASSOCIATE MEDICAL DIRECTORFive (5) years of post residency experience in a recognized medical specialty, at least one year of medical administrative experience preferred. Preferred experience is in ambulatory care and hospital care with Family Medicine or Internal Medicine training. Utilization Management experience for an IPA, medical group or HMO highly desirable. Experience with Medi-Cal managed care is a plus.

Valid, unrestricted Physician’s and Surgeon’s Certificate issued by the State of California. (A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon’s certificate is filed in the state of California prior to date of appointment.) Board Certification with one of the American Specialty Boards. Primary Care Physician, preferably in Family Medicine or Internal Medicine with an unrestricted California medical license.

PHARMACY PDE MANAGERBachelor’s degree in accounting, finance or equivalent is preferred. Minimum one (1) - three (3) years experience in Medicare Part D and analyzing pharmacy data. CMS Financial reconciliation experience is preferred. PDE experience is required.

Proficient with Microsoft Office Products with the emphasis on MS Excel, SQL, and MS Access. Experience in MARx, pharmacy claims systems and accounting general ledgers is a plus. Ability to interpret detailed data and develop accurate, meaningful and reliable reports for management while meeting ongoing deadlines. Excellent written, organizational, data entry and interpersonal skills is required. Able to handle multiple demanding tasks. Ability to work and make independent decisions, maintains confidentiality, be an effective communicator and work with other team members. Capable of working with minimal supervision. Ideal candidates must have strong problem solving abilities

DIRECTOR OF NETWORK DEVELOPMENTBachelor’s degree required. Master’s degree preferred. Five (5) or more year’s experience with IPA’s/medical groups and an in-depth knowledge of all aspects of managed care operations with extensive of HMO operations, contracting, provider relations, project management, and claims processes with emphasis on contract negotiation and analysis.

Analytical skills, time management, and problem solving. Must have a high degree of patience, excellent communication, interpersonal and organizational skills. Microsoft applications Word and Excel are required.




http://hcmarketplace.com/primary-care-collection





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

DIRECTOR, MEDICAL MANAGEMENT

Direct medical management program including utilization management, case management, quality improvement and credentialing in accordance with the mission, philosophy, and objectives of plan and in conjunction with Corporate goals and objectives.

Responsibilities: Develop department objectives and organize activities to achieve objectives. Evaluate and implement changes to medical service functions and performance in relation to company mission, philosophy objectives and policies. Manage budget and forecast for strategic planning and key initiatives. Coordinate with operating departments on research and implementation of best practices. Responsible for the statistical analysis of utilization data on programs. Participate in NCQA, State, and/or other accreditations of the Plan. Organize and present new concepts, programs and tools to staff and other plan departments. Develop communication plans with external providers such as hospitals and State agencies as required to facilitate plan goals and objectives. Coordinate with Medical Director to educate and communicate expectations with providers.

Education/Experience: Bachelor’s degree in Nursing, related field, or equivalent experience. 7+ years of nursing, quality improvement, and management experience in a healthcare environment, preferable managed care. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.

License/Certification: RN license.

Please submit your resume to [email protected]

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

CARE MANAGER – HOME TO PROVIDER Req. #15-1952

CMTY HEALTH WORKER - HOME TO PROVIDER Req. #15-1951

COMPLEX CARE MGR RN – BILINGUAL SPANISH Req. #15-1879

CORPORATE MEDICAL DIRECTOR (SOCAL) Req. #15-1874

DATA ANALYST SR. – HEALTHCARE SERVICES Req. #15-1840

DATA ANALYST SR. – HEDIS & MEDICARE STAR Req. #15-1694

DATA ANALYST SR. (PROVIDER SVCS) Req. #15-1837 HEALTHCARE ANALYST SR. Req. #15-1919

HEALTHCARE INFORMATICS ANALYST II Req. #14-1588

MEDICAL MANAGEMENT SPECIALIST– VH REQ. #15-1900

NETWORK MANAGEMENT LEAD Req. #15-1890

NETWORK MANAGEMENT SPECIALIST Req. #15-1891

PHARMACY ANALYST Req. #15-1739

PROJECT MANAGER – PHARMACY Req. #15-1907

SALES SYSTEM COORDINATOR Req. #15-1939

SQL DATABASE ADMINISTRATOR Req. #14-1591

TELEPHONIC MONITORING SPECIALIST Req. #15-1883


http://www.healthleadersmedia.com/healthfax/free_trial.cfm

www.healthleadersmedia.com





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

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

Director, Provider Networks/Relations #323082Bachelor’s degree required, 7-10 years of experience in Provider Relations, Customer Service, Credentialing or equivalent experience; Must have expertise in managed care provider portals and a minimum of 5 years management experience.

OPERATIONS• Manager, Accounting • Manager, System Contracting• Managed Care Analyst• Claims Adjuster (Seaside Health)

INFORMATION SERVICES• Clinical Application Specialist (Radiant)• Business Systems Specialist (Tapestry)

CLINICAL• RN Supervisor• RN Assistant Supervisor• LVN, Case Manager (Seaside Health)• FOA Supervisor

• Practice Manager• RN Team Lead• Complex Nurse Specialist• FOA Team Lead

• Case Manager P/T & Per Diem• Manager, Coding Compliance• OP Ancillary/Physician Coder• And many more----------

• And many more----------

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





The Inpatient Medical Director will oversee the daily activities of AppleCare Hospitalist Group and be responsible for managing issues pertaining to all acute, skilled and institutional inpatient stays, including providers, staff and facilities. The Inpatient Medical Director will be responsible for developing and instituting programs and long range planning pertaining to hospitalist services in conjunction with the Chief Medical Officer.

Responsibilities and Functions:

• Oversight and management of inpatient performance system-wide

• Establish new relationships and maintain existing relationships within our network at the facility and provider level

• Seek innovative solutions to improve performance metrics

• Train and develop hospitalist staff, both employed and contracted

• Direct oversight of employed hospitalist team

• Develop collaborative relationships with the entire care team including inpa-tient case management, outpatient case management, palliative care and social work

• Arrange hospitalist schedule and conduct monthly hospitalist meetings

• Manage, review and share hospitalist data biweekly with management team

• Leadership role in hospital committees

• Provide direct patient care on a limited basis as necessary

• Maintain hospital privileges at all core hospitals

• Work closely and cooperatively with senior management

• Responsible to meet bed day performance targets of mature managed care

organizations

Requirements:

• Board certified in Internal Medicine with Hospitalist experience

• Current MD/DO license required

• Five years’ minimum experience required; familiar with managed care sys-

tems, processes and standard performance metrics

INPATIENT MEDICAL DIRECTOR

For immediate consideration, please email/fax resume with salary requirements: [email protected] or Fax 714.443.4540

SENIOR DIRECTOR OF INSTITUTIONAL PERFORMANCE

As a Senior Director, you will oversee financial performance and clinical metrics of institutional business, including all hospital risk pools and hospital-ist team managing patients in acute and skilled nursing levels of care. The Senior Director will investigate requests and problems, make presentations to senior leadership, ensure data documentation is accurate and ensure perfor-mance achieved is at or above target levels. Pertinent data and facts will be reviewed to identify and solve issues and mitigate risks, prioritize your work load, and work on ad hoc projects as required.

This position requires dedication to performance improvements across the institutional line of business in an objective way. The Senior Director will resolve complex issues and identify new opportunities by applying strategic insight, intellectual honesty, and analytical structure coupled with process improvement experience to achieve results.

Responsibilities and Functions:

• Payment Integrity Analysis and Execution

• Cost Reduction and Containment

• Review financial and clinical analyses, forecast, and trend data across all levels of care and recommend/execute appropriate initiatives

• Present analysis and interpretation for operational and business review and planning

• Support short and long term operational/strategic business activities

• Develop recommended business solutions through research and analysis of data and implement when appropriate

• Lead initiatives to increase efficiency and maximize the revenue opportunities while leading innovation and collaboration with internal/external partners

• Review, create, and/or maintain workflows to ensure they are up-to-date

and operationally efficient

• Provide guidance, expertise, and/or assistance to internal and/or external

partners (e.g., claims; call center; benefits; clinical) to ensure programs and

strategies are implemented and maintained effectively

• Responsible for monitoring the performance and capacity of daily operations

and reporting operational/performance metrics (daily/weekly/

• monthly/quarterly/yearly) to the leadership team

• Responsible for setting critical goals and upholding a high standard of opera-

tional performance throughout the teams

• Proactively escalate risks and issues to leadership, resulting in timely and

effective resolution

• Partner across the organization to ensure cross functional support and suc-

cess of institutional programs

Requirements:

• 10+ years health care experience, including at least 5 years of payer strat-

egy, contracting, operations and/or related experience

• 5+ years of interpreting provider contractual information, hospital and phy-

sician contracting expertise

• Extensive knowledge of risk pool administration and physician billing

Documents

TOP STORIES Kaiser Adopts More Stringent Rules for Flu ...content.hcpro.com/pdf/10-05-2015_California_HealthFax.pdf · 10/5/2015 · Clara County executive Jeff Smith said delays