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March 23, 2015 | VOLUME 22 | NUMBER 12

T O P S T O R I E S

Hospital Best Practices Reduce Healthcare-Acquired InfectionsBut C. difficile infections jump 5% The incidence of most major healthcare-acquired infections at California hospitals declined in 2013 due in large part to best practice guidelines. A report from the California Department of Public Health (CDPH) showed that “California hospitals have demonstrated progress in preventing HAIs com-pared with national baseline data.” A notable exception was Clostridium difficile infections, which increased in part due to “the emergence of more infectious and more virulent C. difficile strains.” The largest year-to-year decrease among HAIs was in Methicillin-resistant staphy-lococcus aureus (MRSA) infections, which decreased from 817 cases in 2012 to 698 in 2013. Overall, hospitals reported 2,836 central line-associated blood infections, down from 2,998 in 2012. For individual hospitals, 61 demonstrated significant decreases in HAIs from 2012 to 2013 while 112 reported a high rate of HAIs in 2013. The number of surgical site infections (SSIs) increased to 3,940 cases compared to 3,661 in 2012 but the increase was attributed to “more thorough surveillance methods” implemented in 2011. The report also showed that SSIs were lower than the national average for 21 of 24 surgical procedures and that the incidence of SSIs has declined 44% since 2008. Overall, a total of 18,780 HAIs were reported by the state’s 420 hospitals in 2013. C difficile infections were by far the most common with 10,553 cases reported in 2013, up 5% from 2011. C. difficile infections are a common cause of diarrhea in hospital patients and can lead to additional complications and longer hospital stays. California hospitals have been addressing healthcare-acquired infections with pro-grams like Patient Safety First, a collaborative effort with Anthem Blue Cross and 160 hospitals in the state that has produced a 43% reduction in central line infections since 2010 and a 26% reduction in sepsis mortality. Debby Rogers, RN, vice president of clinical performance and transformation for the California Hospital Association (CHA), said the overall decrease in the incidence of HAIs is due in large part to hospitals following best practice guidelines such as fre-quent hand-washing and proper CLIP (central line insertion practice) procedures. She

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Hospital Best cont. » The California Franchise Tax Board

has revoked the tax-exempt status of Blue Shield of California, a deci-sion that Blue Shield plans to appeal. According to a report from the Los Angeles Times, the ruling was made following a state audit of Blue Shield, which is a not-for-profit organiza-tion. “Blue Shield as a company and management team firmly believes it is fulfilling its not-for-profit mission and commitment to the community,” Blue Shield said in a statement. State insurance commissioner Dave Jones said he agreed with the decision. “The Franchise Tax Board decision to termi-nate Blue Shield’s tax-exempt status confirms what I have said for years; that Blue Shield charges excessive rates and acts like a for-profit health insurer,” said Jones.

» UC San Francisco Medical Center and John Muir Health have finalized an agreement to launch an initiative called the Bay Area Accountable Care Network. According to a joint press release, the two systems filed an appli-cation for a restricted Knox-Keene license with the state Department of Managed Health Care that would allow both health systems to contract directly with health plans. “We intend to offer this network to health plans who serve patients throughout the Bay Area,” said Mark Laret, CEO of UCSF Medical Center. “We look forward to working not just with each other, but with other health organizations throughout the Greater Bay Area in

said the improvements are also a function of minor changes that have been added to best practice guidelines over the years. “Years ago, hospitals would shave [the surgical area of] patients the night before surgery using a regular razor,” said Rogers. “But eventually, we learned that shaving caused micro-abrasions that could later be infected so we switched to an electric razor. So there’s a process of constant refining and correcting.” She said the increased incidence of C. difficile is more difficult to address than other HAIs, given the nature of the infection. “For a problem like central line infections, you’re able to focus on a single area,” said Rogers. “But with C difficile, you’re looking at a multi-faceted problem with multiple causes that include antibiotic use and infections originating in other areas of care. So part of the problem is beyond the scope of basic hospital care.” The CHA and other organizations are looking to develop additional programs. “We’re now gearing up for a new round of federal funding and we’re hoping to secure funding for a Hospital Engagement Network to address C. difficile,” said Jan Emerson-Shea, vice president of external affairs for the CHA. A study published in the March issue of Infectious Disease Special Edition touched on some of the issues that make C. difficile difficult to control, noting that it has been “refractory to control efforts that have been put in place to this date.” The study noted that C. difficile is resistant to alcohol-based products but that soap and water and bleach-based cleaning products could be more effective at killing C. difficile spores. —DOUG DESJARDINS

Study Questions Benefits of Integrated Healthcare Systems Critic says study used insufficient dataA new study questions the effectiveness of integrated healthcare delivery models and suggests there is little evidence to prove that they’re effective at lowering costs. The 44-page study from the National Academy of Social Insurance (NASI) looked at 15 different integrated delivery network (IDN) programs operated by major health systems that include Advocate Health Care in Chicago, Johns Hopkins Medical Center in Baltimore, and Sacramento-based Sutter Health. It notes that the programs coordinate care among hospitals, physicians, and other facilities in an effort to “pare down the volume incentive inherent in fee-for-service medicine” and focus on preventive care. But the report concluded that “there is scant evidence” to prove that IDNs have lowered costs or improved care.

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order to provide an exceptional health-care experience for patients.” As part of the agreement, UCSF and John Muir also plan to integrate their electron-ic health record system to coordinate patient care.

» The Cal i fornia attorney gen-eral’s office is holding a March 23 public hearing to discuss a proposed affiliation between Lodi Health and Adventist Health. The meeting at Lodi Memorial Hospital will allow the public to comment on the proposed affilia-tion and provide a venue for a consul-tant to deliver a Health Care Impact Statement on the proposed affiliation. Last December, members of the Lodi Memorial Hospital Association voted to move forward with the affiliation, which would make the 190-bed hospital and its outpatient clinics part of the Adventist Health system. Lodi officials said affiliating with Adventist Health would provide Lodi Memorial Hospital with greater financial stability as part of a larger health system. Adventist is based in Roseville and operates 19 hos-pitals in California, Hawaii, Oregon, and Washington.

» Sutter Medical Foundation plans to consolidate its Placer County can-cer treatment services into one facil-ity. Sutter plans to start construction on the 60,000-square-foot medical building in May in the city of Roseville. “We’re trying to develop a compre-hensive cancer center for our Placer County patients,” said Eric Rasmussen,

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“This analysis was not intended to denigrate these fine institutions,” said Jeff Goldsmith, the study’s lead author and an associate professor of public health sci-ences at the University of Virginia. “Rather, it is intended to address whether the way they have organized care creates measurable benefits to society or, for that matter, to the institutions themselves. If these benefits exist, we could not find evi-dence of them in their public disclosures …” The study contends that “hospital integration into health plan operations and risk-based contracting was not associated with either clinical efficiency (e.g. short-er lengths of stay) or financial efficiency (e.g. lower charges per admission).” It also sought to compare the costs for end-of-life care at flagship hospitals to costs at local competitors and found that “in 12 of the 15 cases where comparison was pos-sible, the IDN flagship hospital had higher total medical spending in the last two years of the patient’s life vs. its in-market competitor.” In the recommendations section of the study, it suggests that hospitals oper-ating IDNs should provide “more detailed routine operating disclosures that would enable financial analysts, academic researchers, and the policy community to understand the performance of IDNs’ subsidiary businesses and the overhead and revenue allocation strategies they pursue.” Some healthcare policy experts questioned the report’s findings and the data it used to reach its conclusions. “The data and study design are simply inadequate to address what the authors set out to do,” said Steve Shortell, PhD, a Blue Cross of California Distinguished Professor of Health Policy and Management and director of the Center for Healthcare Organizational and Innovation Research. Shortell also contends that the study on end-of-life care costs at flagship hospitals included in the report doesn’t reflect the performance of the IDNs. “The authors couldn’t get any data at the IDN level so looked instead at two years of data for flagship hospitals for end-of-life care,” said Shortell. “And even that study didn’t look at things like severity of illness and other factors that would influence costs.” Jill Yegian, interim CEO and senior vice president of programs and policy for the Integrated Healthcare Association, said the study missed the big picture. “The important point is that the IDNs are receiving mixed messages,” said Yegian. “While some of their reimbursement has moved to value-based payment, much has remained fee-for-service. In essence, these systems are operating with one foot in each of two canoes.” —DOUG DESJARDINS

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director of growth and development for the Sutter Medical Foundation. The first floor of the building will be used for surgery and the second floor will include 47 infusion bays for people undergoing chemotherapy. The third floor will feature a pharmacy, physi-cian offices, and offices for the Sutter Medical Foundation. Construction is expected to be complete in July 2016.

» Dignity Health has filed an applica-tion for a limited HMO license with the state Department of Managed Health Care (DMHC). According to a report in the Sacramento Business Journal, Dignity submitted the limited-license request to provide care for Medicare patients in Kern County, where it has three hospitals. “At this time, we do not have plans to expand our use of the limited Knox-Keene license beyond Kern County,” said Dignity CFO Michael Blaszyk in a statement. A limited HMO license does not allow providers to market a plan to the public or directly enroll members but allows providers to share savings with health plans.

» Kim Milstien this month became the CEO of Ventura County Medical Center and Santa Paula Hospital. Milstien assumed her role as CEO on March 1 and succeeded Cyndie Cole, who announced her resignation last September. “We are extremely for-tunate to find someone with Ms. Milstien’s experience, particularly at such an important time in Ventura County Medical Center’s history,” said

Report Says Counties Need to Adjust Indigent Health Plans Demographics of uninsured population have changedA new report suggests that many counties need to revamp their indigent care plans to accommodate the changing demographics of the remaining uninsured. The report from advocacy group Health Access California found disparities in how different counties provide healthcare for the uninsured through county-run plans. The report notes that most county programs don’t provide coverage for undocumented immigrants while others are too restrictive to accommodate low-income people who still can’t afford health insurance even with the help of federal subsidies. According to estimates from researchers at the University of California, approximately 3 million state residents remain uninsured. “More than four million Californians have new coverage and options through the ACA [Affordable Care Act],” said Health Access executive director Anthony Wright. “Now is the time to reflect on the remaining uninsured.” Wright said even though “counties have traditionally been the provider of last resort” for the indigent, county officials tend to “interpret that responsibility in dif-ferent ways.” The study found that only 10 of the state’s 58 counties offer health-care to undocumented immigrants beyond emergency care. Counties are also deal-ing with the effects of Assembly Bill 85, a 2013 bill that reduced state funding for county indigent health programs on the assumption that healthcare reform would reduce the uninsured population. The study notes that there’s a “major variance” in terms of income eligibility for county indigent care programs, “with some counties setting their limit at—or just above—the federal poverty level (Los Angeles, Santa Cruz), while others (San Francisco, Santa Clara) serve patients at several times the poverty level.” Fresno County limits indigent care to people with incomes of up 114% of the FPL while San Francisco County provides care for people with incomes of up to 500% of the FPL. “Many counties with restrictive eligibility requirements have few, if any, people getting care through their programs,” said Wright. “We need counties to readjust their safety-net programs to serve the need that continues to this day.” The study notes that Sacramento, Contra Costa, and Yolo counties stop serving undocu-mented immigrants under their indigent care programs in 2009 but are now dis-cussing plans to fully or partially restore those services. A bill that would address the problem of healthcare for undocumented immigrants will be considered by the state legislature this spring. Senate Bill 4 authored by state Sen. Ricardo Lara (D-Bell Gardens) would create a state-run program to provide healthcare coverage for the estimated 1.5 million undocument-ed immigrants who are uninsured. —DOUG DESJARDINS

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April 8-9. 2015 Statewide Telehealth Summit. Resort at Squaw Creek, Lake Tahoe. A two-day forum focused on best practices and new developments in the telehealth industry. Sponsored by the California Telehealth Network and the Telehealth Resource Center. To register, please visit http://www.caltelehealth.org/2015-telehealth-summit

April 14. CMA Legislative Advocacy Day. Sheraton Grand Sacramento. A one-day educational event for physi-cians, medical students, and healthcare advocates. Sponsored by the California Medical Association. To register, please visit https://www.cmanet.org/events/detail/?event=cma-legislative-advoca-cy-day

April 14-15. Annual Palliative Care Summit. Sacramento Hilton Arden West. An educational forum for physicians, nurs-es, and other healthcare providers focused on new trends and policies impacting pal-liative care. Sponsored by the Coalition for Compassionate Care of California. To reg-ister, please visit http://coalitionccc.org/training-events/annual-conference/

April 17-19. California Society for Healthcare Attorneys Annual Meeting. Hyatt Regency Huntington Beach. An educational event with a focus on new developments and upcoming changes in California health law. To register, please visit http://www.csha.info/events

Barry Fisher, director of the Ventura County Health Care Agency. Milstien most recently served as CEO of Simi Valley Hospital and prior to that served as vice president of business development at Glendale Adventist Medical Center.

» A study published in JAMA Pediatrics suggests that low vaccination rates for measles was partly responsible for a measles outbreak that began at Disneyland in December 2014. Researchers at Boston Children’s Hospital and the Massachusetts Institute of Technology found that individuals who were exposed to measles shortly after the initial outbreak at Disneyland had vaccination rates of 86% or less, a rate well below the 96% rate required to maintain herd immunity. “Clearly, MMR (measles, mumps, rubella) vaccination rates in many of the communi-ties that have been affected by this outbreak fall well below the necessary threshold to sustain herd immunity, thus placing the greater population at risk as well,” the report stated. According to the California Department of Public Health, 133 state residents have been diagnosed with measles since last December. More than half of patients with a known vaccination history were either unvaccinated or did not receive the required number of shots to make the measles vaccine effective.

» The U.S. Food and Drug Administration (FDA) released final guidance on new rules that will require medical device manufacturers to provide proof that new devices can be readily disinfected and sterilized before they are approved for use. The guidance was released in response to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) at two California hospitals earlier this year linked to a specialized endoscope that was difficult to disinfect due to a recent redesign. The FDA will now require device manufacturers to submit pre-approved data that shows devices can be effectively disinfected and sterilized after they are used. UCLA Ronald Reagan Medical Center reported seven cases of CRE and Cedars-Sinai Medical Center reported four cases linked to an endoscope device that has also been linked to CRE outbreaks at other hospitals.

» Antelope Valley Hospital is disputing allegations that it was forced to tempo-rarily shut down its emergency department on Feb. 27 because of a power failure that caused its electronic health record (EHR) system to crash. In early March, the California Nurses Association issued a press release that said Antelope Valley shut down its ED for a short time following a power outage that disabled the hospital’s EHR system. But the hospital said in a statement that the emergency department “continued to treat patients” and that “certain patients were diverted to other near-by facilities based on their treatment needs.” Antelope Valley, a 420-bed hospital located in Lancaster, said the emergency department remained open while hospital officials worked to identify the problem that led to the power outage.

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EDITORIAL SUBMISSIONS

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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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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.

Medical DirectorAssist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Responsibilities: Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Oversees the activities of physician advisors.

Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred.

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VP, Quality ImprovementOversee all related activities for the Quality Improvement functions. Lead and direct process improvement activities for more efficient and streamlined workflow.

Responsibilities: Responsible for all activities related to National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance ensuring highest level of accreditation. Manage all aspects of HEDIS improvement activities, including outreach, incentives, data integrity and chart review. Review and implement new technological tools and processes and foster team concept with internal and external constituencies.

Education/Experience: Bachelor’s degree in Nursing or related clinical field. Master’s’ degree preferred. 10+ years of healthcare operations experience, including quality improvement and NCQA accreditation experience. Experience managing acquisition and integration of external data sources.

Director, ContractingCoordinate, negotiate and handle activities of the provider contracting, network development and/or provider relations functions and aid in formulating and administering organizational policies and procedures. Negotiate large hospital, physician groups and ancillary service agreements

in accordance with Corporate, health plan and government regulations and guidelines.

Responsibilities: Oversee provider contracting activities to ensure efficiency and maintain compliance with Company policies and standards, government laws and regulations. Negotiate contracts with hospitals, physician groups and ancillary service agreements. Develop and implement a network development plan for the assigned region and set of providers and identify and initiate contact with potential providers in support of the Company’s strategic goals and objectives.

Education/Experience: Bachelor’s degree in Business Administration, Health Care Administration, related field or equivalent experience. 5+ years of related experience negotiating hospital, large physician groups and ancillary service agreements and external customer service for providers.

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Manager, Compliance & Reporting Design and implement programs, policies, and practices to ensure State and Federal program contract compliance, as well as compliance with federal and state legal and regulatory requirements.

Responsibilities: Manage the compliance/reporting staff. Oversee the day-to-day health plan policies and procedures to ensure federal and state regulatory compliance. Validate state and federal deliverable reports for accuracy and ensure timeliness of submission. Review and analysis of health plan deliverables and data to identify trends in performance and opportunities for improvement.

Education/Experience: Education/Experience: Bachelor’s’ degree in related field. 4+ years of compliance/regulatory experience in a health care and/or managed care setting/organization. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

HEDIS Coordinator Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities. Assist with quality improvement initiatives in the service and clinical areas.

Responsibilities: Coordinate, complete, and update management on clinical quality metrics and HEDIS processes and results. Establish and maintain an action plan to improve HEDIS score. Implement process to request and evaluate member compliance reports for each HEDIS measure, including evaluating improvement opportunities.

Education/Experience: Education/Experience: Bachelor’s degree in related field or equivalent experience. 3+ years of quality improvement or healthcare related experience. Working knowledge of the National Committee on Quality Assurance (NCQA). HEDIS requirements preferred.

Manager, Care ManagementPerform duties to conduct and manage the day to day operations of the care management functions communicating with departmental and plan administrative staff to facilitate daily department functions.

Responsibilities: Manage the delivery of services to members, ensuring services are appropriate and cost effective. Ensure compliance with government and company requirements in the care management department. Develop and implement new procedures, regulatory filings and manage compliance issues. Develop, implement, and oversee care management policies and procedures and give specific guidance to staff and departments as appropriate.

Education/Experience: Education/Experience: Bachelor’s degree in Social Work, Sociology, Psychology, Nursing, Gerontology, related field or LPN/RN. 6+ of long term care related experience. Thorough knowledge of case and/or utilization management. Familiarity with Medicaid managed care practices and policies, CHIP, and SCHIP.

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We are currently looking for a Director to oversee our exciting Regional Referral Program! The Director will promote and maintain positive physi-cian relations and hospital partnerships, provide proactive leadership for associated physicians, specialty physicians, and the overall program. Do you have a history of building strong physician relationships, along with sales experience? If so, than this may be a perfect position for you!

The hospital Ministries of St. Joseph Health represent a regional destina-tion dedicated to meeting the healthcare needs of Northern California com-munities with compassionate care, progressive treatments, and advanced specialty services.

The Regional Referral Program expands the Ministries’ regional presence to communities with limited access to specialty physicians, advanced medical and surgical care, including Trauma. The program’s scope includes an acute and non-acute presence in the primary and secondary services area. These areas include Sonoma, Mendocino, Napa, Humboldt and Lake Counties.

Requirements:

• Bachelor’s degree, Master’s preferred

• 5 years’ experience in physician relations, sales, managing a clinical prac-tice, service line program or a combination of thereof

To apply, please visit our career site at: http://www.stjoesonoma.org/Careers.aspx

At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.”

Contracts Manager (San Ramon, CA)

Manage the process for health plan and provider contracting. Analyze, negotiate, implement and monitor HMO, physician group, hospital and ancillary provider contract terms.

Director, PPO Programs (San Ramon, CA)

Ensure the company meets the financial/clinical goals of its PPO product lines. Develops and implements new strategies to meet changing market demands.

Manager, Compliance Quality & Enrollment, Claims (San Ramon, CA)

Responsible for managing the operational quality, claims training programs, and all regulatory compliance audits.

For more information on these positions and to apply online, please visit www.HillPhysicians.com/careers

NAMM California, a leader in the Managed Care industry, has the following career opportunity:

Director of Payor Contracting – Ontario, California

Responsible for the Director of Payor Contracting. Position is accountable for preparation, negotiation, implementation of health plan contracts in department. Responsible to build, develop operational processes to support company’s strategic direction for contracting.

Responsibilities:Oversee, manage day to day operations of Payor Contracting Department. Supervise employees in Department. Delegate, monitor, control work prog-ress on key metrics, key initiatives projects, staff productivity, administra-tive expenses. Participate in strategic planning process. Work closely with COO, IPA Executive Directors to accomplish company contracting goals and objectives. Establish operations initiatives for key metrics improvement (health plan product profitability, contracting process, health plan/provider relations). Oversee Departmental budgets.

Qualifications:Bachelor’s degree or equivalent; or two to five years’ related experience and/or training; or equivalent combination of education, experience. 3–5 years equivalent experience related to health care field. 1-2 years manage-ment experience of contracting process from preparation, negotiation & implementation with ability to understand key contract structures and their financial implications. Understanding of healthcare industry, physi-cians market, managed care alternative delivery systems, federal and state regulations.

To apply log on to: www.NAMMCal.com

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

√ Director of Risk Management

√ IT Project Manager

√ Manager of Provider Relations

√ Clinical Program Manager – Disease Management

√ Public Relations Manager

√ Pharmacy Technician

√ Legal Assistant

√ Health Education Program Supervisor

√ Administrative Assistant

√ Compliance Specialist

√ Claims Quality Assurance Analyst

√ Manager of Quality Improvement

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

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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

Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

VICE PRESIDENT, INTEGRATED CAREWe are seeking an executive who will be responsible for leading the development and expansion of Humana’s relationships with delegated risk entities (primarily IPAs) across California. Based within our Irvine or Torrance office, this role reports to the California Market President and serves as the primary leader for the expan-sion of our Integrated Care model across the state. This is a strategic, innovative and results-oriented role with broad responsibility for provider group performance metrics, provider relations service strategy, medical management relationships, process management and quality (Stars).

Our ideal candidate will bring a combination of provider and managed care leadership experience to this role, with deep experience in building relationships with physician executives and other healthcare leaders in IPA environments. Prior business leadership with financial accountability is required, as insight gained from experience in functions such as provider network development, IPA administration or oversight, Medicare risk contracting, and clinical quality. Please send qualifications to rberg1@humana.com

FINANCE DIRECTOR, CA SENIOR PRODUCTSOur search is focused on identifying an executive candidate who will serve as the #1 Financial Leader for Medicare Advantage in the California Market. Based within our Irvine or Torrance office, this role reports to the California Market President, and contributes to the financial strategy, integrity and profitability of the market. As a member of the California Senior Leadership Team, this role will provide direction and administration of all financial aspects of programs, products and services, and have responsibility for 2-4 direct reports and a team of 12 or more associates.

The ideal candidate will possess broad managed care financial leadership experience including prior responsibility for directing the strategic financial business planning, financial analysis/reporting and MA bid development for a managed care Medicare/Medicaid health insurer. Please send qualifications to rberg1@humana.com

NON-CLINICAL SPECIALISTAs a Specialist, you will contribute to the success of Humana’s business strategy by collecting broad based information and gathering resources and data in order to arm the team with the tools necessary to enhance consumer engagement, choice, and trust. Req. #138487

UTILIZATION MANAGEMENT SPECIALISTThis is a telephonic position making outbound calls to facilities, updating electronic authorizations, generating letters, and working in the hub of our utilization manage-ment team. As a Utilization Management Specialist you will: make outbound calls to providers to obtain clinical information, update electronic authorizations, using your analytical skills to manage your caseload and pull reports, document your conversa-tions with providers, update the status of authorizations, field inbound calls to the region and support the clinical team. Req. #138379

CLAIMS ANALYSTThis analyst role will perform analysis of claims to ensure accuracy of payment. This is accomplished both in-house and by contracting vendors with expertise in their areas. The ideal candidate will possess previous claims processing experience within the healthcare industry. Req. # 131237.

PROJECT MANAGERAs a Project Manager you will manage, analyze, strategize, create, improve, and implement new operational processes across various functional areas of Humana and the CA market. You will evaluate the effects of process changes by quantitatively and qualitatively measuring them against internal and external benchmarks. In addition, you will oversee the application of project manage-ment methodology during all phases of the project cycle, with responsibilities including project design, scope management, cost control, and both quality and performance reporting. Req. # 139123

BUSINESS ANALYSTBased within our Walnut Creek office, this analyst role will provide research and analytical support to a team of associates during the design, development and implementation of Humana products. The position will analyze project requests, maintain timelines, determine requirements and feasibility, and docu-ment process workflow for all services. The ideal candidate will possess previ-ous healthcare insurance experience, and a bachelor’s degree in business or a related field. Req. # 140589

RAF/MRA MANAGERThis manager role will oversee day to day operations, process improvements and achieve performance metrics for a fast paced work environment; Actively coordinating with STARS team, Provider Relations/Contracting with key pro-viders to improve risk scores; Develop team members and create department process flows; Develop, validate and implement data mining strategies for new processes; Oversee encounter data capture and submission from MRA perspec-tive. Present HCC/RAF performance results and findings regularly to delegated risk groups. Responsible for provider educational activities and projects. Please send qualifications to svanterpool@humana.com

RAF/MRA PROCESS CONSULTANTThis consultant role will require project management. As a Process Consultant you will manage, create, improve and implement new processes across MRA and the delegated providers/group. This position will be responsible for projects across delegated providers/ risk groups in the region including provider education, data analysis & audits. Serves as a liaison to clients (internal/external) by managing and implementing new processes, and formulating enhancements and improvements to existing processes; and as a focal point for all cross functional areas. Req. # 138303

To apply for these and other career opportunities, please visit http://careers.humana.com. Search for the Requisition Number listed above or send resume as noted in the job description.

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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

ApplyNowWe’re rapidly growing … We have new and

exciting opportunities for:

• RN - Hospital Care Manager • Medical Director

• Project Manager – Health Center Development

• Human Resources Business Partner (HRBP)

• Healthcare Data Analyst

Visit our website regularly for updates on new positions!

Apply Now: www.culinaryhealthfund.org

Competitive compensation and benefits including a fully funded employer paid pension plan, BCBS medical, dental, vision, 401(K), Flex-Spending Account, 12 paid holidays and generous PTO!

Kern Health Systems (KHS) is the largest health plan in Kern County, serving over 192,000 local members. We are currently seeking the following positions to join our team! At KHS, we are dedicated to improving the health status of our members through an integrated managed healthcare delivery system. This is an excellent opportunity to join an organization with excellent benefits, career advancement, and professional growth opportunities.

• Claims Supervisor

• Payroll Supervisor

• Pharmacist

• Provider Relations Manager

• Senior Data Analyst

• Senior Database Administrator

• UM Clinical Intake Coordinator RN I

• Claims Examiner

Benefits:

We have an excellent benefit package which includes: health insur-ance, dental, life, Vision, 457(b) and 401(a) Plan, PTO and EIB, CalPERS and other company benefits.

If you want to learn more about these great opportunities please visit our web-site at kernhealthsystems.com or come by our Human Resources Department, 9700 Stockdale Hwy. Bakersfield, CA 93311, Fax 661-664-4310, business hours are Monday-Friday 8:00am to 5:00pm-email resume to: recruitment@khs-net.com.

“Kern Health Systems is a tobacco-free facility”

NOTE: As a condition of employment, a satisfactory drug test and background check is required. E.O.E

Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

CLINICAL PERFORMANCE IMPROVEMENT CONSULTANT

The Performance Improvement Consultant will be accountable for developing and maintaining key business relationships and optimize business results. This is a work from home opportunity. The ideal candidate will possess a background in provider education, field services, knowledge of the Central CA market, experience in HEDIS and Member Perception- CAHPS/HOS. The position will report to the Star Quality Director. Req # 139549.

To apply for these and other career opportunities, please visit http://careers.humana.com. Search for the Requisition Number listed above or send resume as noted in the job description.

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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!

ACCOUNTING SUPERVISOR

High School Diploma or equivalent required. Associate degree in Accounting preferred. Five (5) or more years experience in an accounts payable, accounts receivable or general accounting environment; minimum of three (3) years in a supervisory capacity. Intermediate to advance Microsoft Office skills (Excel, Word etc.). Experience with ERP systems Oracle a plus.

BUYER III

Bachelor’s degree in Business Administration or related field required. Professional certification from a national body (e.g. ISM or NIGP) is preferred. Five (5) years of purchasing related experience required. Governmental purchasing experience preferred; public works purchasing experience a plus. Ability to communicate clearly and effectively, including in a persuasive manner at times, with outside vendors as well as all levels of the IEHP team.

FINANCIAL ANALYST

Bachelor’s degree required. Minimum of one (1) year of Finance or five (5) years General Ledger experience. Experience in Managed Care preferred. Experience in developing complex reports using financial reporting software. Experience in statutory reporting a plus. Strong knowledge and demonstrative proficiency utilizing Microsoft Applications (Word, Excel, Access & PowerPoint). Strong understanding of accounting and financial principles and methodologies. Experience with SQL, Oracle and Hyperion a plus. Principles and practices of health care industry and strategies, health care systems, capitated risk contracting, provider network structures and risk sharing arrangements a plus.

INPATIENT REVIEW NURSE MANAGER

State of California RN License or LVN with a bachelor’s degree required. Possession of a bachelor’s degree referred. Possession of a valid California driver’s license and auto insurance. Under the direction of the UM Director-Inpatient, responsible for the oversight of the Inpatient Review Nurses. Hospital experience and three (3) or more years experience with medical groups and an in-depth knowledge of all aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis on Concurrent Review and utilization management. Self-starter and team player. Analytical skills, time management, and problem solving. Knowledge of Microsoft Applications required (Word, Excel). Must have a high degree of patience, excellent communication, interpersonal and organizational skills. Knowledge of evidence based clinical criteria and CCS.

PHARMACY CALL CENTER & TRAINING MANAGER

Bachelor’s degree preferred. Education requirement may be waived if candidate has extensive supervisory experience in a healthcare call center environment and training experience. California State Board of Pharmacy Technician License required. Three (3) years prior call center supervision. Two (2) years of training experience. Knowledgeable in call center supervisory applications and training modalities/tools. Ability to balance multiple projects and meet deadlines with high quality output. Five (5) or more years of healthcare call center experience with training supervision and working in a health care delivery setting.

Proficient in Microsoft applications (Microsoft Word, Excel). Excellent written and verbal communication, interpersonal skills, ability to establish and maintain effective working relationships with others, ability to supervise and train team members strong organizational skills, detailed oriented, and sound decision making skills required. Experience in an HMO, managed care, Knowledge in Medi-Cal, Healthy Families, Healthy Kids, and Medicare Programs preferred.

PHARMACY MEDICARE PART D ANALYST

Bachelor’s degree required. CPA license desired. Minimum one (1) - 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 with 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.

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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

PHARMACY UTILIZATION MANAGER

Pharm. D. from an accredited institution required. California State Board of Pharmacy, registered Pharmacist License. Five (5) or more years of individual or combined experience in clinical pharmacy setting, preferably in an HMO, Managed Care, or specialty Pharmacy setting. Clinical residency preferred. Under the direction of the Pharmacy Medical Director, the Pharmacy Utilization Manager is responsible for providing manager level management and leadership of the Financial and Utilization Unit. Responsible for the direction, coordination, implementation, and management of the financial and utilization programs. Knowledge related to Medicare Part D, PDE, utilization trends, budgeting, and financial forecasting preferred.

PROVIDER AUDITOR

Bachelor’s degree preferred. Possession of a valid California driver’s license and valid auto insurance. Four (4) years claims processing experience in a managed care environment, two (2) years claims auditing experience and two (2) years experience working with Providers. AAPC Certification a plus. Working knowledge of Medical Group and HMO operations, claims delegation, compliance and contract interpretation. Solid understanding of DMHC, DHCS, CMS, and MRMIB regulations for claims adjudication practices and procedures for Medi-Cal and Medicare claims. Working knowledge of audit processes and protocols, strong organizational skills, effective writing and communications skills and computer proficient. Ability to interact with all levels of management and establish and maintain strong business relationships with plan partners.

QUALITY MANAGEMENT MANAGER

Bachelor’s degree in business or health field, or a valid RN license issued by the State of California, required. Possession of a valid State of California driver’s license. Three (3) or more years experience in a Quality Assurance Program with a hospital or HMO. Microsoft applications (Microsoft Word, Excel, Access) skills required.

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

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

CLINICAL PHARMACIST – CDAG Req. #15-1716CODING QUALITY SPECIALIST SR. Req. #15-1696, 15-1697COMMUNITY SERVICES RN Req. #14-1519DATA ANALYST SR. – HEDIS & MEDICARE STAR Req. #14-1521, 15-1693, 15-1694DATA ANALYST, SR – HEALTHCARE SERVICES Req. #15-1722DIRECTOR ACTUARIAL SERVICES Req. #14-1610DIRECTOR CONSUMER INSIGHT Req. #15-1688FACILITY SITE REVIEW NURSE Req. #14-1660HEALTHCARE INFORMATICS ANALYST II Req. #14-1588MANAGER CLAIMS - AUDIT & RECOVERY Req. #15-1734MANAGER IT SECURITY Req. #15-1695 MEDICAL MANAGEMENT SPECIALIST (REMOTE) Req. #15-1717MEDICAL MANAGEMENT SPECIALIST – RN Req. #15-1703NETWORK MANAGEMENT SPECIALIST Req. #15-1728NURSE PRACTITIONER (STOCKTON, CA) Req. #15-1711PHYSICIAN ASSISTANT (STOCKTON) Req. #15-1723PROGRAMMER ANALYST II Req. #15-1738 RECOVERY SPECIALIST Req. #15-1735REG’L CONTRACT MGR – NETWORK MGMT Req. #14-1581SR. BUSINESS ANALYST – DIGITAL STRATEGY Req. #15-1726SQL DATABASE ADMINISTRATOR Req. #14-1591

Executive Director of Network ManagementThe Executive Director of Network Management is responsible for provid-ing senior level leadership, guidance and oversight over the MCMF Network Management department. They will develop, lead and align the execution of strategic plans for the expansion of services and primary and specialty physi-cian networks in support of all Foundation networks and entities.

This position is responsible for establishing a collaborative team that executes the strategies of the Foundation including the direction and oversight of pro-grams designed to foster positive relations between physicians, hospitals or healthcare facilities and health plans.

The position is responsible for all aspects of network management including contract administration, negotiations, provider relations, credentialing, and customer service (including member services).

Qualifications:Bachelor’s degree from a college or university or equivalent/relevant experi-ence required. Master’s degree preferred. A minimum of 10 years of experi-ence within a managed care environment. Minimum of 5 years directly with an IPA or medical group in a Provider Relations environment.

To learn more about this opportunity and to submit an application, please visit our Career website at:

http://www.memorialcare.org/careers and search Req. #321560.

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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

HEALTHCARE PARTNERS MEDICAL GROUP, a division of DaVita HealthCare Partners, Inc. (DVA: NYSE), is a top-rated medical group and is widely recognized for its achievements in clinical excellence and patient satisfaction. Since 1992,

HealthCare Partners has been committed to developing innovative models of healthcare delivery that improve patients’ quality of life while contain-ing healthcare costs. HealthCare Partners manages and operates medical groups and affiliated physician networks in Arizona, California, Nevada, Florida, New Mexico, and Colorado. As of Sept. 30, 2013, HealthCare

Partners provides integrated care management for approximately 760,000 managed care patients.

We are committed to bringing the benefits of coordinated care to our patients and to taking a leading role in the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all. If you’re looking to make a difference with a large, financially stable, well-recognized medical group, DaVita HealthCare Partners may be the employer for you.

Immediate Opportunities:

Regional Contract Negotiator – Req # 17437 - Torrance. Responsible for developing, implementing contracting strategy for assigned region. Negotiate hospital, physician, ancillary contracts. Coordinate financial analyses with relevant departments; presents finding to regional, senior management. Interface with MCA, Claims, Care Management, IMCS, Payor Contracting, other departments to coordinate contract documentation.

Contract Specialist 2 – Req # 17317 – Costa Mesa. Responsible for iden-tification, negotiation of contracts with providers for both existing and developing provider networks. Ensure proper administration of contracts through assessment of provider needs, coordination of contract documen-tation, interfacing with MCA, Claims, IMCS, Care Management and others as necessary.

Clinical Research Compliance, Senior Manager – Req # 17320 - Torrance. Responsible for development, implementation of research compliance program. Utilize previously acquired project management, analytical and other expertise to work with, build a knowledge base around wide variety of functional areas.

Manager, Regional Care Management – RN – Req # 17124 – Torrance. Responsible for oversight, management, optimization of quality improve-ment, utilization management, care management activities related to pre-admission, ambulatory case management, and other health care delivery programs. Manage team members and daily operations of care manage-ment programs.

RN, Utilization Management Compliance – Req # 16034 – Torrance. Responsible to review, write referral denials, work with health plans to provide information for appeals to assure regulatory compliance and to educate Care Management departments on regulatory requirements from regulatory organizations.

For immediate consideration please apply online at www.healthcarepartners.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

Desired Skills• Principles and practices of managed care, quality management and of

effective contracting and monitoring of the application of contracts.

• Internal audit practices and activities.

• Federal and state regulatory and other requirements and practices related to Medi-Cal (Medicaid), Title 22, Knox-Keene, as well as other gov-ernmental and public sector operations and practices.

• Effective methods and techniques for persuasion and enforcement, com-pliance and effecting change and managing staff, coordinating work of interactive groups.

• In depth knowledge of HIPAA regulations, related federal, state laws and health care accreditation standards.

Experience & Education• Bachelor’s degree in Health Care Administration or other related field

required.

• Master’s degree in Health Care Administration, Business Administration, Public Administration, Clinical Area, or Law and Health Care Compliance certification preferred.

• 10+ years of experience in a leadership role in a managed care organiza-tion.

• Medi-Cal and Medicare experience highly preferred.

Position Responsibilities• Oversee and monitor all aspects of the implementation of the compli-

ance program, including an annual schedule of compliance activities.

• Provide ongoing reporting on activities to the Chief Executive Officer, and to the organization’s Finance and Audit Committee of the Board.

• Develop and implement training programs for internal staff and sub-contractors such as Code of Conduct, Fraud, Waste, and Abuse, Privacy and Information Security.

• Ensure compliance with new laws, regulations and directives. Develop internal processes to coordinate activities with departments and functions.

• Develop and implement internal compliance reviews and monitor activi-ties (including financial and operational compliance reviews). Conduct routine internal audits to include, but not limited to, the claims adjudica-tion process and member rights.

• Develop and implement external compliance reviews on subcontractors, contracted provider groups, and third party vendors.

• Develop policies and procedures that encourage management, employ-ees, and members to report any suspected fraud.

• Provide leadership in coordination with others in the organization for the implementation of all HIPAA development activities.

• Proactively work with managers to improve organizational effectiveness.

• Act as the liaison between CalOptima and OIG for fraud and abuse issues.

• Maintain CalOptima compliance policies and ensures regular policy review.

See website for job details and to apply:

https://www.caloptima.org/en/Careers.aspx. CalOptima offers an excellent work environment, including a highly competitive benefits package.

APPLY HERE

CalOptima is a public agency that administers health insurance programs for more than 700,000 low-income children, adults, seniors and people with disabili-ties in Orange County, California. CalOptima is the top-ranked Medi-Cal plan in California, according to the NCQA’s Medicaid Health Insurance Plan Rankings 2014–2015. A mission-driven organization, CalOptima focuses on health care quality and access as well as innovation and care coordination to remain a recog-nized leader in publicly funded health care programs.

Compliance OfficerExecutive level position reporting to the CEO and the Board of Directors

The position serves as the Compliance Officer for the organization and is responsible for coordinating and communicating assigned compliance activities and programs. Implements, monitors compliance program. Ensures company meets state, federal regulatory, contractual requirements. Interacts with CalOptima executive and management, health network management, legal counsel, state, federal representatives and others. Supervises Compliance department staff. Responsible for internal compliance, auditing activities; developing, implementing annual compliance plan for company business lines; regular reporting to CEO and Board members.

Responsible for oversight for delivery of health care services via subcontracts with provider network at the subcontracting health plan and direct provider levels. The position oversees a comprehensive, and complex program, including compliance professionals with expertise and responsibilities for the following areas: Medicare and Medi-Cal compliance, audit and monitoring, fraud, waste and abuse, special investigations, privacy, participating provider group oversight, policies and procedures, and organization-wide compliance training.

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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 employ-ees. 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.

CAREER OPPORTUNITIESVice President, Human Resources – LB Memorial Medical Center #320836 Bachelor’s degree in Business or Human Resources, minimum 10 years of experience performing HR functions, at least five years as a Director of Vice President of Human Resources required. SPHR preferred.Executive Director, Information Services #320894 Bachelor’s degree in Computer Science, Computer Engineering or related field; Masters preferred. 10 years IS management & 5 years EPIC experience in patient financial and clinical applications.Regional Director, Clinical Operations North #321312 Bachelor’s degree in Business, Healthcare Administration or Nursing, Master’s degree preferred. 10 years of management experience in an ambulatory setting including medical practice or clinical mgmt.

OPERATIONS• Decision Support Financial Analyst• Provider Relations & Contract• Medical Management Data Analyst

• Manager, Contracts Managed Care• Practice Manager• And many more----------

INFORMATION SERVICES• Director of Applications & Project Support• Project Manager (EPIC)• Clinical Applications Specialist (EPIC)

• Business Systems Specialist (EPIC) • And many more----------

CLINICAL• RN In-Patient Care Manager• Clinical Risk Manager• Clinical Risk Manager• QI Supervisor• RN Supervisors & Team Lead

• LVN Supervisor• Clinical Project Manager• Regulatory Compliance Nurse• LVN Supervisors & Team Leads• 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