Job req ID: 6764
The Enterprise and Network Oversight Business Analyst III (BA III) is an integral part of supporting the department in maintaining a centralized, integrated, proactive Enterprise Performance Optimization Program (Enterprise POP) and a Network Performance Optimization Program (Network POP) to ensure Plan and Network performance excellence.
The BAIII individually and collaboratively researches federal, state, contractual, accreditation, and Plan-imposed requirements applicable to the Enterprise and L.A. Care’s Plan Partners and Provider Network for all lines of business (Medi-Cal, Personal Assistance Services Council (PASC-SEIU), L.A. Care Covered (LACC) and LACC Direct (LACC/D), and the Cal MediConnect Program (CMC) and Dual-Eligible Special Needs Plan (D-SNP)).
The BAIII is responsible for maintaining subject matter expertise of all performance standards corresponding to an assigned scope of responsibility. For any given project or issue, the BAIII identifies and actively engages a complete group of stakeholders to assure that related fiscal and operational impacts, and risk and liability-producing factors attendant to the implementation of requirements or policy are properly considered and adjudicated by the right parties.
In collaboration with key stakeholders, the BAIII performs proactive gap and risk analyses; track, trend, analyze, and report results to enable leadership to make evidence-based decisions to remediate extant deficiencies and engage in process improvement to achieve optimal internal and external performance. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff. Elicits, documents, analyses, communicates, tests, verifies, and systematically tracks federal, state, contractual, accreditation, and Plan-imposed requirements for the Enterprise, the Provider Network, and L.A. Care’s Plan Partners.
Performs criteria-based internal and external monitoring, proactive gap analyses and risk assessments; reports results and collaborates to take corrective action and perform ongoing performance improvement planning. Ensures that L.A. Care, its Plan Partners, Network, and vendors demonstrate adherence to applicable requirements in timely updated policies and procedures, workflow(s), and other artifacts.
Oversees all phases of Enterprise, Network, and Plan Partner performance related to an assigned scope, including: helping to research and distill requirements into actionable form and set performance standards, developing and monitoring metrics to track ongoing fidelity to these requirements, and taking corrective action to remediate issues of non-compliance. This including establishing Key Performance Indicators (KPIs or Metrics) to systematically assess, track, and trend internal L.A. Care performance and external Network and Plan Partner performance.
Partners with the functional business leaders, Compliance, Legal, and Quality Improvement to coordinate responses to regulatory inquiries and actions, and to the NCQA, and assists in preparing for and responding to internal and government audits; examines audit findings and collaborates to respond to cited deficiencies; and monitors implementation of corrective action plans.
Proactively informs the organization, senior Leadership, and relevant committees, including the Internal Compliance Committee (ICC) of possible risks and issues with sub-optimal internal and external criteria-based performance, and develops remediation and corrective action plans, as appropriate. As a Subject Matter Expert, develop and conduct training on unit processes, for lower-tiered positions.
Performs other duties as assigned.
At least 5 years of experience in contract and/or regulatory and/or accreditation requirements analysis in managed care or other related industry; or, experience in Healthcare Compliance, or other Compliance-related field.
Education: Bachelor’s Degree
Preferred: Master’s Degree Juris Doctor Degree or Doctor of Law Degree
Title: Network Installer Location: Virginia As a Network Installer, the candidate will be involved in all facets of network, video, desktop,...Apply For This Job
Job req ID: 7008 Job description The Claims Assistant supports the handling and routing of all documents received through the claims...Apply For This Job
Job req ID: UCCE-RRB092921960 Job description Onsite Requirement: 5 days per week Main duties & responsibilities or project/s resource will focus on:...Apply For This Job