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July 27, 2015 | VOLUME 22 | NUMBER 29

T O P S T O R I E S

Daughters of Charity Signs Affiliation Deal with Investment Firm Hospitals to be managed by Integrity Healthcare The Daughters of Charity Health System (DCHS) signed an affiliation deal with BlueMountain Capital Management that would provide $250 million in capital for the DCHS system.

The deal would also give BlueMountain, a private investment firm based in New York City, an option to acquire the hospital system after three years. The proposed deal, which is subject to approval by the state attorney general, was announced July 17 about four months after a merger between DCHS and Prime Healthcare Services fell through.

“In evaluating candidates to manage the hospitals, our priority was to seek the strongest bidder who could provide the greatest long-term stability while honoring the obligations to our associates, physicians, retirees, and constituents,” said DCHS president and CEO Robert Issai. “The transaction represents and extremely attrac-tive option for DCHS, allowing it to continue its operations and mission as a non-profit system with the backing of strong and well-qualified partner organizations.”

Under terms of the agreement, a division of BlueMountain called Integrity Healthcare “will provide key management services and day-to-day operational support” while BlueMountain will provide $250 million in capital to allow DCHS to “repay certain outstanding obligations, provide operational liquidity, and invest in physical plant improvements and operations.” Blue Mountain will also assume all col-lective bargaining agreements with hospital unions and all pension and retirement plans for DCHS employees. The hospitals will be governed by a five-member, indepen-dent board of directors.

The management team for Integrity Healthcare includes Mitch Creem and Mark Meyers. Creem has 33 years of experience in the healthcare industry including stints at Keck Hospital of USC and the UCLA Health System. Meyers has 22 years of experience as a hospital executive and CEO including stops at Dignity Health and Glendale Memorial Hospital.

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» Adventist Health has namedJennifer Swenson as president andCEO of Simi Valley Hospital (SVH)effective Aug. 17. Swenson has morethan 20 years of healthcare financeand operations experience and mostrecently served as corporate vice presi-dent of the Kettering Health Networkin Ohio. “Not only does Jennifer haveproven business skills, she shines inareas of working with employees, phy-sicians, boards, and the community,”said Beth Zachary, president andCEO of the Southern California Regionfor Adventist Health. Swenson willreplace Kim Milstien, who resigned inNovember 2014 and was replaced onan interim basis by Caroline Esparza,senior vice president of patient careand chief nurse executive for 153-bedSimi Valley Hospital.

» St. Joseph Hoag Health will opena wellness center at Western Digital’sworld headquarters in Irvine. The4,600-square-foot multi-specialty well-ness center is scheduled to open bythe end of July and will offer primaryand preventive care services for morethan 1,800 employees. “St. JosephHoag Health is partnering with localbusinesses because we truly believethat we can have an impact on help-ing people attain a healthier lifestyleif we are more available to them inplaces where they live and work,” saidAnnette Walker, executive vice presi-dent of strategic services for St. JosephHoag Health. The center will providepreventive services like blood tests and

Daughters of Charity cont.

One industry analyst said the agreement with BlueMountain is a good deal for DCHS because it will keep the health system intact. When DCHS began shopping for a buyer last year, officials said they were willing to consider offers to sell off individu-al hospitals but preferred to sell the entire health system to one bidder. “It keeps the health system in one piece so it’s a good move on their part,” said Steve Valentine, president of Los Angeles-based healthcare advisory firm The Camden Group.

Valentine said cost-cutting measures implemented by DCHS earlier this year should make the transition easier and less likely to include layoffs. In May, DCHS announced plans to reduce services at several hospitals, changes that resulted in the loss of approximately 280 jobs or about 4% of its total workforce. At the time, DCHS said the cuts were designed to reduce expenses and “and better position our hospi-tals” while it searched for a buyer. “It made them more attractive to bidders and now they won’t have to make as many changes,” said Valentine.

The DCHS system includes St. Vincent Medical Center in Los Angeles, St. Francis Medical Center in Lynnwood, O’Connor Hospital in San Jose, Saint Louise Regional Hospital in Gilroy, Seton Medical Center in Daly City, Seton Coastside in Moss Beach, and the DCHS Medical Foundation.

Daughters of Charity said it has been losing up to $10 million per month and was interested in teaming with a larger partner. The chain pursued a merger with Ascension Health but negotiations fell through in late 2014.

DCHS then entered negotiations with several potential buyers before settling on a deal with Prime Healthcare. But that agreement fell apart in April when Prime balked at conditions imposed by California attorney general Kamala Harris that included keeping five of six DCHS hospitals open for at least 10 years. Prime had originally agreed to keep all hospitals open for at least five years. —DOUG DESJARDINS

Studies Show Access to Care Still a Problem for Medi-Cal PatientsDental care not on par with Medicaid patients in other statesTwo new studies show that access to care is a bigger problem for Medi-Cal patients than for people with employer-based coverage or for Medicaid patients in other states.

The first study titled “Medi-Cal Versus Employer-Based Coverage” found that 18% of nonelderly adult Medi-Cal patients do not have a usual source of healthcare other than the emergency department, compared to 8% of patients with employer-based coverage. The study conducted by the UCLA Center for Health Policy Research and the California HealthCare Foundation also found that 35% of

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exams along with primary care, physi-cal therapy, acupuncture, chiropractic, behavioral health services, and an on-site pharmacy.

» The California Department of Public Health (CDPH) announced that California has seen an increase in the number of syphilis cases among women, pregnant women, and new-borns over the past two years. “The increase in congenital syphilis is partic-ularly concerning,” said Karen Smith, MD, CDPH director and state health officer. “It is a needless tragedy that can be prevented with good prenatal care and timely and effective treat-ment.” The CDPH reported that from 2012 to 2014, the annual number of early syphilis cases among women more than doubled from 248 cases to 594 cases. The annual number of con-genital syphilis cases during that time more than tripled from an annual aver-age of 30 cases to 100 cases per year. “It is vital that pregnant women get comprehensive prenatal care, including getting tested for STDs, to avoid trans-mitting infections to their babies,” said Smith. The CDPH said it has increased outreach efforts to enroll pregnant women in prenatal care programs in an effort to reduce syphilis rates.

» Gold Coast Health Plan (GCHP) has hired Patricia Mowlavi as its new chief financial officer. Mowlavi has more than 20 years of experience in managed healthcare and most recently served as senior director of accounting and

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adult Medi-Cal enrollees reported fair or poor health compared to 11% of patients with employer-based coverage.

In terms of access to care, 36% of adult Latino Medi-Cal patients who speak a language other than English at home reported being told that a doctor would not take them as a new patient compared to just 7% for the overall Medi-Cal population.

“When you have that big of disparity, it points to communication problems with providers and Latino patients,” said study author Shana Alex Charles, director of Health Insurance Studies for the UCLA Center for Health Policy Research. “Providers are supposed to provide interpretive services, so that indicates there’s a barrier to care that’s not supposed to be there.”

The study also found that 6% of adult Medi-Cal patients reported problems finding a doctor who would accept them as a patient compared to 2% for people with employer-based coverage. “That doesn’t sound like a big difference but it’s major when you consider that the Medi-Cal population in general has more health problems and a greater need for care than people with employer-based coverage,” said Charles

A companion study titled “Medi-Cal versus Medicaid in Other States: Comparing Access to Care,” found that access to care for Medicaid patients in California was comparable to Medicaid patients in other states with some exceptions.

The study showed 52% of nonelderly adult Medi-Cal patients did not visit a den-tist in 2013 compared to 46% of Medicaid patients in other states. It also found that 69% of those Medi-Cal patients did not receive a flu vaccination compared to 60% of patients in other states, and that 10% of Medi-Cal patients delayed needed care because of difficulty in scheduling an appointment compared to 5% for Medicaid patients in other states.

Access to care in those areas was also a problem for children with 25% of chil-dren with Medi-Cal coverage going without a dentist visit in 2013 compared to 19% of children in other states with Medicaid coverage. The study concludes that Medi-Cal is providing care about as well as “Medicaid in other states on many dimensions” but that “with Medi-Cal in a period of significant change, it will be important to con-tinue monitoring gaps in access to care.”

A report from the state Department of Finance shows Medi-Cal spending has increased with the influx of 2.28 million new patients into the system since the start of Medicaid expansion in 2013. Department of Finance data shows Medi-Cal spend-ing increased from $91.5 billion in fiscal 2011 to $115.3 billion in fiscal 2016 and that Medi-Cal now accounts for 16% of state General Fund spending compared to 14% in fiscal 2011. —DOUG DESJARDINS

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financial services at L.A. Care Health Plan. Prior to joining L.A. Care, Mowlavi spent 10 years at Blue Shield of California where she served as finance director. “Patricia has an impressive track record in managed healthcare and will be a wonderful addition to the GCHP executive team,” said Gold Coast chief executive Dale Villani. Gold Coast provides healthcare services for more than 189,000 Medi-Cal beneficiaries in Ventura County.

» The Cal i forn ia Department of Public Health (CDPH) confirmed the first death from West Nile virus in California this year. The deceased was described as a senior citizen who lived in Nevada County. “This death is a tragic reminder of how severe West Nile disease can be,” said CDPH direc-tor Karen Smith, MD. “West Nile virus activity is more widespread in 2015 than in years past, and Californians need to be vigilant in protecting them-selves.” To date, 33 counties have reported West Nile virus activity this year, four more than at this time last year and well above the five-year aver-age of 22 counties. West Nile virus is transmitted by mosquitos and can lead to serious illness in older people or peo-ple with compromised immune systems.

» The director of the California Department of Managed Health Care (DMHC) likened Aetna’s recent premium hike for the small employer market to “price gouging.” According to a report in the Los Angeles Times,

Tobacco-Related Bills Re-Introduced for Special Legislative Session Bills would raise smoking age and create new e-cigarette lawsA half-dozen tobacco-related bills designed to reduce smoking and create new rules for e-cigarettes were re-introduced for a special legislation on healthcare scheduled for late summer. The bills authored by state senators Mark Leno (D-San Francisco) and Ed Hernandez (D-West Covina) would introduce a number of changes in state tobacco laws that include raising the minimum smoking age from 18 to 21 and subjecting e-cigarettes to the same regulations that govern cigarette smoking in public places. The state Assembly and Senate are currently out of session on summer recess for several weeks and will announce a date for the special session after they return on Aug. 17. Leno’s legislative package includes Senate Bill 2X-5, which is based on leg-islation he introduced earlier this year but withdrew in July after it was amended by an Assembly committee. “Decades ago, the tobacco industry tried to fool us into believing that filtered cigarettes were a healthier alternative to tradi-tional cigarettes and now they’re making the same claims about e-cigarettes,” said Leno. “The fact is that they’re using a new delivery system that is currently addicting the children of California to toxic nicotine.” SB 2X-5 is based on Senate Bill 140, a bill that was approved by the state Senate but hit a roadblock in the Assembly Governmental Organization Committee when it was amended to state that e-cigarettes were not a tobacco product. The bill would ban e-cigarettes in the same public places that cigarette smoking is banned and require e-cigarette packaging to be child-resistant. Sen. Hernandez on July 16 re-introduced Senate Bill 2X 7, which would raise the minimum age to buy tobacco products in California from 18 to 21. That bill is based on Senate Bill 151, which Hernandez temporarily withdrew from consider-ation in the Assembly Governmental Organization committee earlier this month. “Tobacco companies know that people are more likely to become addicted to smoking if they start at a young age,” said Hernandez. “While our previous attempts to protect California’s youth from this deadly drug came up short, the governor’s call for a special session provides us with a perfect opportunity to fur-ther pursue this policy.” Other legislation due to be considered at the special session includes bills that would require all schools to be tobacco-free zones, allow local jurisdictions to tax tobacco, and add hotel lobbies, small businesses, tobacco retailers, and employer break rooms to the list of smoke-free workplace areas. —DOUG DESJARDINS

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Aug. 20-21. USC Sixth Annual Pain Management Symposium. University of Southern California, Los Angeles. A two-day seminar focused on the latest advanc-es in pain management and new trends in patient-centered care for managing pain. To register, please visit http://www.keck.usc.edu/events/6th-annual-pain-manage-ment-symposium-from-evidence-to-clini-cal-practice/

Sept. 1. California Cancer Reporting Conference. 2015 & Beyond. Hilton Sacramento, Arden West Hotel. A one-day event featuring seminars focused on changes in cancer reporting stan-dards at the state and federal level. Sponsored by the California Department of Public Health. To register, please visit http://calcancersymposium.org/

Sept. 13-15. HFMA Fall Conference. Southern California and San Diego/Imperial Chapters. Hyatt Regency Long Beach. A conference for health-care finance professionals with an emphasis on new payment models and programs created under federal health-care reform. To register, please visit http://hfmasocal-sandiegofallconf.org/

Sept. 30. 14th Annual IHA Stakeholders Meeting. Hilton Los Angeles Airport Hotel. An annual forum for California value-based care, pay-for-performance participants to share best practices. Sponsored by the Integrated Healthcare Association. To reg-ister, please visit http://www.iha.org/con-ferences_events.html

Aetna raised premiums July 1 an average of 21% for about 13,000 people with small employer coverage in the state. DMHC director Shelley Rouillard said that her request that the insurer reduce its rate hike was rejected by Aetna executives. “Aetna’s pattern of unreasonable increases equates to price gouging in today’s mar-ket,” said Rouillard. “I strongly encourage small employers subject to these unrea-sonable rate increases to explore more affordable health coverage options.” Aetna said its rate increase was necessary based on projected medical costs and that “our rates are based on actuarially sound data and a reasonable projection of future cost.” Rouillard disagreed with Aetna’s statement and said the insurer did not provide adequate documentation to justify the rate increase.

» The 2015 Kids Count report from the Annie E. Casey Foundation found that California has made significant improvements in children’s health programs due in large part to federal healthcare reform. According to a report in the San Francisco Chronicle, California improved its state ranking for overall children’s health from 26th ’in the U.S in 2008 to 14th in 2013. The report found that a key contributor to that improvement was a drop in the rate of uninsured children, which decreased to 7% in 2013 from 11% in 2008. But California ranked second-to-last in the report in the category of economic well-being, due in large part to a state childhood poverty rate that increased to 23% in 2013 compared to 18% in 2008.

» Three California hospitals were named to the Honor Roll of top hospitals in rank-ings compiled by U.S. News & World Report. Hospitals were evaluated in 16 medical specialties and those that achieved high scores in six or more specialties were named to the Honor Roll. Of the 15 hospitals, UCLA Medical Center was No. 3 in the overall rankings followed by UC San Francisco Medical Center at No. 8 and Stanford Health Care–Stanford Hospital at No. 15. Five hospitals in the state were included on a list of Best Regional Hospitals: Stanford Health, UCLA Medical Center, Cedars-Sinai Medical Center, UC San Francisco Medical Center, and UC San Diego Medical Center.

» UCLA Health System said that it’s working with the FBI to investigate a data breach that could have affected as many as 4.5 million patients. According to a report in the Los Angeles Times, UCLA said there’s currently no evidence that any patient data was taken in the breach but the possibility can’t be ruled out. “We take this attack on our systems seriously,” said James Atkinson, MD, interim pres-ident of the UCLA Hospital System. “For patients that entrust us with their care, their privacy is our highest priority.” UCLA said the initial investigation showed hackers gained access to a part of the health system’s computer network where some patient data is stored.

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EDITORIAL SUBMISSIONS

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tact Doug Desjardins, Editor. By e-mail:

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March 31, 2014 | VOLUME 30 | NUMBER 12

T O P S T O R I E S

Number of Physicians in State has

Increased 39% Since 1993

Many areas still have shortage of physicians

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

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

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

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

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

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

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

state still have a shortage of physicians.

The federal government recommends that communities have between 60 and

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

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

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

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

100,000 residents.

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

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

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

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

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

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

77 specialists for every 100,000 residents.

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

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

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

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

an underserved area of California for three years.

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

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

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

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

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 of Process ImprovementDevelop and implement business process excellence initiatives throughout the organization to analyze and address process and operational inefficiencies by utilizing Six Sigma/LEAN methodologies.

Responsibilities: Develop, direct, implement, and execute business process excellence and process improvement initiatives utilizing Six Sigma/LEAN methodologies, including process mapping and process design. Develop and implement key metrics across the organization to review past, current and future performance of business processes. Evaluate interventions for effectiveness and return on investment. Oversee data analysis and gather processes/programs to establish costs and benefits of process effectiveness and efficiency. Conduct analysis of business processes across the organization, identify gaps in the business process, determine its impact to the organization, and recommend action plans and timeline to address these issues. Collaborate with various functional areas to achieve optimal results in process redesign and implementation of new methodologies. Identify barriers to implementation and develop and propose solutions that address both business needs and customer satisfaction.

Education/Experience: Bachelor’s degree in business, healthcare administration, related field, or equivalent experience. 7+ years of process optimization, process improvement, or project management experience. Experience with Six Sigma/LEAN methodologies. Knowledge of process mapping, process design, and workflow management software and applications.

License/Certification: Six Sigma/LEAN Certification preferred.

Please submit your resume to JMERTZLUFFT@CENTENE.COM

Compliance SpecialistEnsure compliance with contractual requirements and federal and state government reporting and regulations. Maintain government relations for compliance activities.

Responsibilities: Ensure compliance with contract provisions with various agencies and applicable State and Federal laws. Serve as compliance resource for day–to-day processes. Analyze and determine the best course of action for each inquiry/problem. Act as primary contact for initiating and coordinating compliance projects. Develop and update plan policies and procedures to ensure compliance with federal and state requirements. Conduct periodic assessments and audits to ensure compliance with contractual and regulatory requirements and timeliness of submission. Oversee the day-to-day health plan policies and procedures to ensure federal and state regulatory compliance.

Education/Experience: Bachelor’s degree in related field or equivalent experience. 5+ years of compliance or regulatory experience. Advanced experience with Microsoft Office applications. Knowledge of business operations related to managed care preferred.

Please submit your resume to JMERTZLUFFT@CENTENE.COM

Data Analyst IIIResponsible for analytic data needs of the business unit. Handle complex data projects and acts as lead for other Data Analysts.Responsibilities: Provide advanced analytical support for business operations in claims, provider data, member data, clinical data, HEDIS,

pharmacy, external reporting. Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources. Review data to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management. Develop reports and deliverables for management. Model data using MS Excel, Access, SQL, and/ or other data ware house analytical tools. Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analysis. Assist with training and mentoring other Data Analysts.Education/Experience: Bachelor’s degree in related field or equivalent experience. 4+ years of statistical analysis or data analysis. Advanced knowledge of Enterprise Reporting and Analysis tools, SQL, and Microsoft Office applications, including Excel and Access. Experience managing projects or heavy involvement in project implementation. Healthcare experience preferred.Please submit your resume to JMERTZLUFFT@CENTENE.COM

Manager, Medical Review UnitManage the review of medical claims for billing coding, other compliance or reimbursement issues; assist with non clinical aspects of medical review, project management functions.Responsibilities: Manage work flow of medical review unit, assist with policy and procedure development and train staff. Develop, implement and maintain production and quality standards for medical review unit staff. Oversight of standalone office location (daily personnel issues, supplies, staffing, and safety). Investigate medical claims, records for billing, coding, and compliance or reimbursement issues and make payment. Education/Experience: Nursing degree. State registered nursing license, advanced degree preferred. 3+ years nursing experience and 3–5 years of quality improvement and management experience in healthcare environment, preferably managed care. Thorough knowledge of Physician’s Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Edition (ICD-9). Previous experience as lead managing cross functional teams or supervisory experience.Licensure/Certification: RN license.

Please submit your resume to JMERTZLUFFT@CENTENE.COM

Medical Review NursePerform retrospective review of large hospital and physician claims for admission appropriateness, coding, length of stay, and pricing. Review retrospective medical necessity appeals against medical review criteria to make benefit determinations.Responsibilities: Perform retrospective high dollar claims for benefit, pricing-determination. Collect hospital medical records as appropriate and work with related hospital staff. Work with Finance Department to determine appropriateness of pricing. Maintain appropriate records, files, documentation, etc.Education/Experience: Bachelor’s degree in Nursing or related field. Licensed or Registered Nurse. Advanced degree and/ or certification preferred. 2+ years in acute care nursing and utilization review. Knowledge of managed care programs and practices required.License/Certification: Licensed or Registered NursePlease submit your resume to JMERTZLUFFT@CENTENE.COM

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

As a Senior Director, you will oversee financial performance and clinical metrics of institutional business, including all hospital risk pools and hos-pitalist team managing patients in acute and skilled nursing levels of care. The Senior Director will investigate requests and problems, make presen-tations to senior leadership, ensure data documentation is accurate and ensure performance 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 oppor-tunities 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 opera-tions 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 operational 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 success of institutional programs

Level of Experience Desired:

• 10+ years health care experience, including at least 5 years of payer strategy, contracting, operations and/or related experience

• 5+ years of interpreting provider contractual information, hospital and physician contracting expertise

• Extensive knowledge of risk pool administration and physician billing

For immediate consideration, please email/fax resume with salary requirements: HR@AppleCareMedical.com or Fax 714.443.4540

SENIOR DIRECTOR OF

INSTITUTIONAL PERFORMANCE

Member Services Leadership

Inter Valley Health Plan, a regional, not-for-profit, Medicare Advantage Plan with Part D benefit, head-quartered in Pomona, California, has an opening for a Manager or Director of our Member Services area (title will be based on work experience). Reporting to the Vice President, Marketing and Member Services, the Manager or Director, Member Services is responsible for Medicare Member Services operations by planning, developing, managing, and motivating staff to optimize both individual and team performance. This position is responsible for ensuring that member calls are answered timely and with accurate member information with the overall objec-tive of high touch customer service. The manager will audit, coach and train staff to guarantee high quality and seamless delivery of service. The Manager will utilize all measurement tools including, Speech Analytics, TASKE, FACETS and Call Manager to ensure effective employee performance. This position must have excellent written and verbal communication skills.

Requirements Include: • College degree; • must have excellent communication and presenta-

tion skills• Must have approximately 4 years previous experi-

ence in our industry in a leadership role within Customer Service and know Medicare guidelines extremely well as well as interrelated State programs

• Strong experience with customer service interven-tions for training, measuring and developing staff through using various measurement

• Management experience in a Medicare Advantage plan is required, prior customer service experience in a consumer oriented business is a plus

“We offer competitive salary and benefits programs.”

To Apply: Please submit your resume with cover letter to: jobs@ivhp.com

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

Health Essentials was founded in 1996 as a post-acute and long-term care physician network. We are the leader in post-acute, long-term and hospice care for the Southern California market. Headquartered in beautiful Santa Ana with openings throughout southern California, Health Essentials has excel-lent opportunities for professionals to join our growing team!

Director, Finance Operations

The Director of Finance, Operations is responsible for support of the assigned business line with timely and accurate delivery of financial reporting and trends. Act as a financial advisor to the business in budgetary, staff planning and augmentation, optimized revenue creation, and presentation of finan-cial reporting. In this high-profile role, the Director of Finance, Operations will effectively partner with the assigned business line to ensure effective communication and financial strategies are in place for optimized business planning and strategy achievement.

General Responsibilities: • Coordinate with the internal Finance and Accounting Department

regarding all daily financial business operations and implements finan-cial policies, accounting system and cost controls to assure adequate,timely and accurate reporting.

• Assist the President of Patient Care Delivery Division in developmentof the annual budget. Monitor spending levels and allocation of fundswithin budgetary limitations, review and supplements budget varia-tion reports and necessary analytics related information that impactperformance.

• Reviews performance against operating plans and standards. Providesreports to various levels of leadership on interpretation of results, andapproves changes in direction of plans as necessary.

• Presents monthly reports on performance as requested by PatientCare Delivery Division President.

• Conducts monthly analytical reviews of division’s business locationsfinancial results. Communicates highlights of these reviews and makesrecommendations for operational changes to methods processes,approaches or to field leadership.

• Provides communications to Site Leadership and other Division man-agement on operations and financial results. Serve as educator relat-ing to causes of financial effects and managerial decisions that impactsuch financial results.

Qualifications:

• Bachelor’s Degree in Business Administration, Finance, Accounting orrelated field; MBA strongly desired.

• 8 to 10 years previous financial analysis, strategic planning experiencerequired; Operations background strongly desired, healthcare experi-ence required.

• Hands-on working knowledge of budget preparation, variance analysisand strategic planning.

• Able to interact with all levels of management and staff.

• Strong presentation skills with the ability to communicate complexfinancial data and information clearly, accurately and effectively andtarget the information and presentation to the audience.

Health Essentials is a full-service organization that has been providing care to the frail elderly population in California, Arizona and Nevada since 1996. Our family of companies includes a physician-led medical group, three Medicare-certified and CHAP-accredited hospices, pharmacy services and a durable medical equipment (DME) provider. By offering all services under one organization, Health Essentials provides its partners and patients with a complete approach to care that is well-coordinated. Our unique care model allows our healthcare professionals to focus on what matters most: providing physical, emotional and spiritual comfort and care to our patient.

For complete job descriptions on these exciting career opportunities, please visit our Career Center at www.healthessentials.com, or submit a current resume along with salary requirements to resume@healthessentials.com.

Health Essentials is proud to be an Equal Opportunity Employer.

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Telemedicine, Navigation, & Behavioral HealthThe Exceptional ED:

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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

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

Supervisor

√ Senior Decision Support Analyst

√ Health Navigator

√ Utilization Review RN

√ Receptionist

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

Do Work That MattersWe are Sutter Physician Services (SPS) – the industry leader in providing patient access, revenue cycle, and accountable care solutions to health care provider and payer organizations. Together, we are a team of experts passionate about improving the patient experience. Many of our employees have told us that part of what makes SPS a great place to work is the sense of purpose they get from supporting patient care, directly or on behalf of our clients. In other words, they feel they “Do Work That Matters.”

Senior Director of Clinical Services and Population HealthWe are seeking a dynamic clinical leader to oversee all clinical activities related to emerging value-based payment models. The Sr. Director serves as a key clinical liaison with senior executives and clinicians of Sutter Health and its affiliates. 5-10 years’ experience in an ambulatory or inpatient setting, 3-5 years’ experience with senior level clinical management for a large healthcare organization, an advanced clinical degree (RN, OT, Pharm D, DO, MD), a Masters’ Degree and clinical licensure in CA required.

For more information and to apply, please visit www.sutterphysicianservices.org/careers and search for job number 1515553.

Sutter Health Affiliates are Equal Opportunity Employers.

SUTTER HEALTH Sutter Physician Services

HEALTHLEADERS INC. 07/13/20152LA029948B

3.6500” x 4.25” (4c process) MRAMIREZ SUTTE0002

al/al n/a

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.

Vice President, ComplianceEnsure regulatory compliance with state and other government agencies related to the health insurance industry, Centene Corporation, and its business subsidiaries.Responsibilities: Ensure business unit and Centene Corporate are in compliance with state, federal program/insurance regulations, regulatory and state contract requirements. Maintain, track laws, regulations, contract documentations, amendments, and compliance measures. Develop policies, procedures, processes to comply with state/federal law, contract requirements, and standards. Oversee, administer, and implement compliance programs, including fraud and abuse and HIPAA. Provide guidance to departments regarding compliance issues, implementation of new requirements.Education/Experience: Bachelor’s degree in Public Policy, Government Affairs, Business Administration or related field. Master’s or Law degree preferred. 8+ years compliance program management, contract experience. Extensive knowledge of state administrative code, regulations, state insurance laws, regulations including managed care regulations. Experience with state/federal government agencies, accreditation bodies, participating provider agreements, HIPAA and Third Party Administration (TPA) laws, credentialing regulations and prompt pay laws.Please submit your resume to JMERTZLUFFT@CENTENE.COM

Director, Medical ManagementDirect 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 JMERTZLUFFT@CENTENE.COM

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

New opportunities, New challenges, Family cultureJoin a company that is committed to a long-term, integrated, coordinated care strategy and growing nationwide.

• Physician networks in 4 states (CA, TX, RI, NJ)

• 4 Regions in Southern CA

• 260,000 Enrollees

• 19 IPAs

• 13 Hospitals

• 4 - 5 STAR Medicare Advantage rating

• ‘Elite’ status in CAPG’s Standards of Excellence for 4 consecutive years

We have the following opportunities available:

If you want to be part of an innovative health care system dedicated to coordinated and integrated care, send your resume to hr@prospectmedical.com.

Vice President, Provider Network- LA Director, Core Systems (IT) Manager of Compliance (UM/QM) Specialty Pharmacy Manager

Customer Service Supervisor Director, Project Management Office Nurse Practitioner / Case Managers Business Dev. Managers - IE & LA/OC

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

CLINICAL PHARMACIST (FORMULARY) Req. #15-1817

COMMUNITY OUTREACH REP (NORCAL) Req. #15-1807

COMPLEX CARE MANAGER RN Req. #15-1859

COMPLEX CARE MANAGER RN - NFLOC Req. #15-1862

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 DIRECTOR RISK ADJUSTMENT PROGS & AUDIT Req. #15-1827

HEALTHCARE INFORMATICS ANALYST II Req. #14-1588

HEALTH PROMOTION RN Req. #15-1805

MANAGER DIGITAL STRATEGY Req. #15-1744

MANAGER QUALITY ASSURANCE & TESTING Req. #15-1779

PHARMACY ANALYST Req. #15-1739

PROJECT MANAGER Req. #15-1812

RECOVERY SPECIALIST Req. #15-1735

SALES OPERATION SPECIALIST Req. #15-1821

HOT SQL DATABASE ADMINISTRATOR Req. #14-1591

TEMPORARY SALES REP Req. #15-1845

VICE PRESIDENT CALL CENTER OPERATIONS Req. #15-1783

CENTER If you do

receive your copy of HealthFax,

customerservice@hcpro.com.

ption questions,

California Healthfax is

copyrighted by HealthLeaders Media, a division

of BLR, 75 Sylvan St., Suite A-101, Danvers,

MA 01923, and is transmitted solely to the sub-

scriber. Any unauthorized copying, duplication or

transmission is strictly prohibited. Annual sub-

scriptions are $179. For group and bulk subscrip-

Anthem Blue Cross Forms Health

Plan with Seven Health Systems

New plan called Vivity to launch in January 2015

Anthem Blue Cross announced the formation of a new health plan with seven

Southern California health systems that will use an integrated care model and

initially target large employers.

Anthem is teaming with some of the largest healthcare providers in

Angeles and Orange counties to form a health plan called

president of Anthem’s West Region, said Vivity has been in the works for more

than a year and is unique in that rival health systems are joining forces to create an

integrated healthcare system designed to reduce costs and improve quality of care.

“Under the current model of care, hospitals want to keep their beds full,” said

Kehaly. “Under this model, the focus will be on population health and wellness and

keeping people out of the hospital.” She said Vivity brings together “seven compet

ing, top-quality health systems that are fully aligned around the goal of improving

quality of care.”

Health systems participating in Vivity include PIH Health in Whittier

Cedars-Sinai Medical Center in Los Angeles, UCLA Health System

MemorialCare Health System in Long Beach, Torrance Memorial Hospital

Huntington Memorial Hospital in Pasadena, and Good Samaritan Hospital

Los Angeles. Vivity has already received certification from state regulatory agen

cies and will begin enrollment on Oct. 1 with coverage starting on Jan. 1, 2015. The

health plan will include more than 6,000 physicians and 14 hospitals within the

seven health systems.

While the health plan will eventually expand into other areas, the initial focus

will be on large employers. “We will initially be available to companies with 50 or

more employees,” said Kehaly. “We want to keep the focus on one area until we

figure things out and we don’t want to mess things up with too much volume.” The

California Public Employees Retirement System

to use Vivity doctors and hospitals within its

and Orange counties.

Sign up a colleague for a free four-week trial to

California Healthfax

www.healthleadersmedia.com800-753-0131customerservice@healthleadersmedia.com

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

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.

Chief Financial Officer #323216Bachelor’s degree in Health Administration, Finance, Accounting or related field, MBA, CPA preferred. 7 years of experience in financial management.

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

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

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

Director, Populations Health Analytics #323043Master’s degree in Computational Science or Economics, 5 years’ experi-ence in healthcare finance, Population Health, ACO, Health Plan, medical management/cost of care or decision support environment; Proven quan-titative and analytical skills. Experienced in the development of financial analysis, reporting, predictive analytics and claims systems.

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

HOT

CLINICAL • RN In-Patient Care Manager • Practice Manager • RN & LVN Supervisors • Clinical Risk Manager

OPERATIONS • Clinical Project Manager • Manager, Accounting • Decision Support/Financial Analyst I • Manager, Lean Fellow • Case Manager, ACO • Manager, Material Services • Hospitalist Manager • Internal Audit Manager

INFORMATION SERVICES •Director of Applications & Project Support •Clinical Applications Specialist (OpTime) - •Business Systems Specialist (Tapestry) • And many more----------

For subscription services, call 800-753-0131

PAGE 12 of 14 July 27, 2015

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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

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!

ASSOCIATE COUNSELBachelor’s Degree in a related field and Juris Doctorate from a top tier law school. Must have an active license to practice law in California. A minimum of 3-5 years combined experience in a law firm, corporate, or government setting. Federal (CMS) and State agency (DHCS, DMHC) experience highly preferred. Health care law, health plan, hospital operations experience is a plus. Must have strong understanding of regulatory requirements for a public agency in the delivery of health care services.

Strong knowledge of the managed care industry and policy issues impacting managed care. Must possess excellent communication, presentation, interpersonal and research skills. Ability to analyze case law and develop recommendations. Ability to develop and leverage one or more of the following areas of legal specialization: Medicare/Medicaid regulations, health plan operations, and health care transactions. Must have ability to exercise a high degree of initiative to handle and prioritize multiple matters simultaneously and effectively in a high-volume environment.

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.

DIRECTOR OF CALL CENTER SYSTEMS, QUALITY & TRAININGBachelor’s degree in Business Administration or related field, or five (5) years of equivalent work experience in lieu of degree. Previous experience with workforce and forecasting analysis utilizing industry software. Experience in a multi-skill, multi-site call/contact center operation is required. Experience with databases and/or data manipulation. Knowledgeable in call center operations including qualityreview and training experience. Highly organized with the ability to balance multiple projects and meet deadlines. Extensive experience writing policies and procedures and training documentation. Prior project management experience with the ability to work independently with the ability to develop concepts into business operations.

Five (5) or more years of healthcare call center experience working in a health care delivery setting. Experience in an HMO, managed care, knowledge in Medi-Cal, Healthy Families, Healthy Kids, and Medicare Programs preferred. Proficient in microcomputer applications. Excellent written and verbal communication, interpersonal skills, ability to establish and maintain effective working relationships with others, ability to supervise and train team member’s strong organizational skills, detail oriented, and sound decision making skills required. Ability to critically review data and implement operational recommendations. This role requires high degree of patience and strong ability to lead team members through inherent interpersonal challenges.

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.

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

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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

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

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.

MEDICARE PART D ANALYSTBachelor’s degree required. CPA license desired. Minimum one (1) to three (3) years experience in Medicare Part D and analyzing Pharmacy data. CMS Financial reconciliation experience is required.

Under the direction of the director of pharmaceutical services, the Medicare Part D analyst will be responsible for reviewing, understanding, and integrating processes related to Medicare Part D. The analyst will handle complex data projects, review regulations, and assist in project managing processes across departments. Duties related to this position include oversight of; support/resolution of PDE claims, accuracy of

eligibility data, transaction data, cross department communication, and meeting all regulatory requirements. Proficient in Microsoft Applications with the emphasis on Excel and Access. 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 required.

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.

PURCHASING MANAGERBachelor’s Degree in Business or related field is required. Professional certification from a national body (e.g. ISM or NIGP) is preferred. A total of ten (10) years Purchasing experience, at least five (5) years supervisory experience. Governmental purchasing experience preferred.

Current and extensive knowledge of purchasing methods, procedures, and automated purchase requisition and contract management systems. Public Agency contracting principles including RFP/RFQ preparations, Public Works, contract negotiation, contract law and basic financial analysis

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E M P L O Y M E N T O P P O R T U N I T I E S

Clinical Risk Manager Under the direction of the CMO, the Foundation Clinical Risk Manager plans, organizes and administers risk management activities which include, but are not limited to, procurement of insurance coverage and risk financing, analyzing and managing claims made against the company, interfacing with defense counsel, managing and analyzing risk management data, conducting risk assessments on clinical practice and care design processes, providing risk management educational programs, and administering the enterprise risk management program with the goal of minimizing the adverse effects on patients, and/or losses to the organization and enhancing quality of care. Utilizing knowledge of clinical settings, scope of practice limitations, best practices and the legal system to provide clinical consultative services on risk prevention and mitigation strategies. Acts as a resource regarding risk management services and clinical best practices for patient safety.

Assists with the design and implementation of policies and procedures related to loss prevention, patient safety, risk mitigation, patient rights and/or hospital responsibilities incorporating clinical best practice or other professional guidelines as applicable to the appropriate care setting.

Experience: – Minimum 5 years clinical risk management or medical malpractice

legal experience.

Education: – RN licensure or equivalent Health related license required. – Juris Doctor or similar graduate law degree. – Certification in Risk Management desirable.

To learn more and apply, please visit our website at jobs.memorialcare.org