L.A. Care Health Plan

Data Analyst

• Leads end-to-end analytic development
• Conducts advanced analyses
• Coordinates with IT and product owners
• Develops, optimizes, and automates analytic assets
• Provides training and mentorship

Medical Cost Drivers Analytics Data Analyst III

• Collaborates and contributes in the design, development, and delivery of analytic solutions
• Translates defined business questions into structured analytic requirements and specifications.
• Participates in structured requirements elicitation, documentation, and verification.
• Develops and automates recurring reports and dashboards.
• Validates data integrity and ensures compliance with data lineage and governance standards.
• Contributes to analytic code review and continuous integration processes.
• Collaborates with IT, business partners, and fellow analysts to resolve data issues.
• Applies foundational statistical methods to interpret patterns in performance.
• Participates in project tracking and post-implementation review to ensure solutions deliver measurable business value.

Care Delivery Analytics Data Analyst II

• The Quality Improvement Analytics Data Analyst III serves as a Subject Matter Expert (SME) contributor responsible for leading complex analytic projects.
• Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights.
• Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance.
• Develops, optimizes, and automates analytic assets (data models, dashboards, reports).
• Mentors and models adherence to analytic development best practices.

Quality Improvement Analytics Data Analyst III

Customer Success Manager

• Leads the strategy, performance, and operational excellence of the organization’s escalations’ function for all lines of business and across all channels
• Oversees multiple escalation and customer-facing teams
• Ensures complex customer issues are resolved promptly, accurately, and with exceptional care
• Manages customer engagement operations across all Community Resource Centers
• Responsible for driving continuous improvement, reducing escalation volume through root cause analysis
• Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures
• Collaborates closely with executive/senior management to establish goals that align with the company’s mission and vision
• Participates in department budgeting process
• Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s)
• Fosters a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals
• Identifies complex problems and reviews related information to develop and evaluate options and implement solutions
• Monitors adherence to compliance requirements and handles complex or high-profile escalations requiring senior intervention

Senior Manager, Customer Engagement

Operations

• Lead and optimize the day-to-day operational, analytical, and technical functions that support electronic data exchange
• Manage end-to-end operational oversight of inbound and outbound HIPAA-standard and proprietary EDI transactions
• Ensure timely, accurate, and compliant processing of electronic claims, encounters, eligibility updates, and related administrative data
• Oversee transaction monitoring, exceptions, error queues, and data rejects; ensure prompt triage and resolution
• Provide oversight of requirements documentation, including business and functional requirements (BRDs/FRDs), workflow mapping, and data specifications that support operational effectiveness
• Manage complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval
• Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.

Senior Manager, Electronic Data Interchange, Claims Data Operations

Compliance

• Responsible for leading clinical case operations, regulatory interpretation, and clinical decision stewardship across all grievance, appeal, and State Fair Hearing cases.
• Oversees clinical operations teams responsible for medical necessity reviews, clinical grievances and appeals, Quality of Care (QOC) referrals, clinician coordination, clinical documentation quality, and regulatory interpretation.
• Ensures collaboration with Utilization Management, the UM Medical Director, and other stakeholders to support compliant and high-quality case handling.
• Drives performance to ensure the team can lead high-level decisions that impact the success of L.A. Care.
• Manages the development, implementation, administration, and maintenance of the department's programs, policies, and procedures.

Senior Manager, Clinical and Regulatory Operations

Business Analyst

• Facilitate business process improvement via the investigation, analysis, review and documentation of functional business specifications
• Manage the requirements development process through elicitation, analysis, specification and verification of multiple levels of requirements
• Develop report and analysis for the department
• Communicate and coordinate with IT on day-to-day department related efforts
• Manage and coordinate implementation and/or integration of products or new features for clients
• Act as mentor to Business Analysts I/II
• Develop functional and user acceptance test plans and scenarios
• Coordinate functional and user acceptance testing
• Perform data analysis to support evaluation of system defects or to develop requirements for new functionality
• Coordinate activities including on-time delivery, testing and production moves
• Collaborate with I.T. on all department related efforts
• Facilitate collaborative system and data design sessions

Business Analyst III

• Advocates and assists members in navigating their health plan benefits, accessing care, resolving issues, addressing waste and abuse, and connecting to community, clinical, and social services
• Handles complex, sensitive, or escalated cases
• Provides guidance to other advocates
• Collaborates across departments to improve the member experience
• Conducts high-touch outreach to support vulnerable or high-risk populations, including seniors, individuals with chronic conditions, and members with unmet social needs
• Serves as a subject matter expert for benefit interpretation, care coordination pathways, and service workflows
• Resolves escalated inquiries from customer service, care management, and provider relations
• Connects members to community resources related to housing, food, transportation, financial assistance, behavioral health, and other social determinants of health (SDoH) needs
• Supports member engagement initiatives such as health literacy outreach, preventive care reminders, redetermination support, and quality-improvement campaigns

Customer Engagement and Experience Advocate III

QA Engineer

• Leading quality oversight, service excellence, and member experience improvement activities within the health plan’s customer experience operations
• Ensuring customer service teams deliver accurate, high-quality, culturally competent support to members
• Overseeing QA reviews, conducting experience analytics, guiding service improvement initiatives
• Partnering with operational leaders to strengthen performance tied to CAHPS, STARS, CMS/State requirements, and organizational service standards
• Managing all aspects of running an efficient team, including hiring, supervising, coaching, and training
• Developing and maintaining dashboards and reports that track QA outcomes, experience trends, and service performance

Manager, Customer Engagement – Experience Quality Assurance

Manager

• Manages and leads L.A. Care’s pre-payment service validation function
• Oversees processes that independently verify the accuracy, authenticity, and appropriateness of billed services
• Ensures timely, accurate, and thorough completion of validation activities prior to adjudication
• Partners closely with cross-functional key stakeholders to ensure findings lead to upstream improvements
• Supervises, coaches, trains, and motivates direct reports
• Participates in department's strategic planning and long-term decision-making

Manager, Service Validation Unit

Director

• Direct oversight of L.A. Care’s grievance, appeal, and State Fair Hearing functions
• Ensure all cases are processed accurately and consistently with exceptional quality
• Develops strategic plans and drives change
• Collaborate extensively with cross-functional key stakeholders
• Strengthen preventive controls and improve service delivery
• Fosters a culture of proactive issue identification and operational improvement

Senior Director, Grievance Officer – Appeals and Grievances

Auditor

• Evaluates customer interactions across all channels (calls, chat, email, and correspondence) for accuracy, professionalism, empathy, and service quality.
• Verifies representatives provide correct benefit information, follow call scripts, and use approved language.
• Reviews documentation to ensure complete, timely, and accurate recording of member interactions.
• Audits customer interaction records to ensure adherence to CMS guidelines, state Medicaid rules, NCQA standards, HIPAA, privacy regulations, and internal compliance policies.
• Identifies potential compliance risks and flags issues for corrective action.
• Prepares detailed audit reports summarizing findings, trends, and opportunities for improvement.
• Tracks performance results at the individual, team, and process level.
• Participates in Root Cause Analysis (RCA) for recurring quality issues, compliance gaps, or service failures.
• Provides feedback to key stakeholders regarding knowledge gaps, script deviations, or policy misunderstandings.
• Assists with audit readiness for regulatory bodies and maintains documentation.

Customer Engagement, Experience Compliance and Quality Auditor II

• Drive operational performance, regulatory compliance, service quality, and continuous improvement across all appeals and grievance functions.
• Ensure accuracy, completeness, compliance, and audit-readiness of grievance, appeal, and State Fair Hearing case files.
• Manage a comprehensive quality and audit program that includes case accuracy audits, documentation integrity reviews, and timeliness monitoring.
• Collaborate closely with cross-functional management teams to strengthen internal controls and ensure sustainable compliance with regulatory requirements.
• Oversee the development, implementation, administration, and maintenance of the department's programs, policies, and procedures.
• Produce and oversee quality, audit, and compliance trend reporting.

Senior Manager, Appeals and Grievances

• Supports scheduling, forecasting, and real-time monitoring of contact center, back-office and production queues.
• Provides real-time monitoring and management of department’s queues, back-office, and production workload.
• Prepares reports on updates related to call performance, back-office and production workload, service levels, adherence to schedule, and overall staffing.
• Assists in creating ad-hoc reports and analysis as requested by department and senior leadership.
• Documents intraday events and escalates issues to WFM team and department leadership as needed.
• Monitors adherence to schedule activities and excessive state durations, where applicable.
• Collaborates with department leaders to address staff behaviors.
• Recommends real-time schedule changes.
• Identifies efficiency opportunities.
• Optimizes scheduled breaks and lunches as resource requirements change.
• Determines the need for extra work hours and/or early departures.
• Assess availability for offline functions and approves/denies as required.
• Reviews and responds to schedule change requests.
• Assists with the creation of all schedule runs and schedule bids/changes.
• Supports senior analysts by organizing historical data used for work volume and staffing forecasts.
• Helps identify patterns or variances in work volume trends.
• Supports skilling activities to respond to real-time workload queue conditions.
• Uses established guidelines, process exception requests as submitted by department’s agents and supervisors within the assigned timelines.
• Processes exceptions to schedules to support training, coaching and meeting requests while ensuring that there is adequate coverage for all departments channels.
• Performs other duties as assigned.

Workforce Management Analyst I

• Supports the operations by forecasting workload, planning staffing, creating schedules, and monitoring real-time performance of contact center and back-office production queues.
• Analyzes historical workload data to develop volume forecasts.
• Builds staffing models to identify required headcount based on service levels.
• Tracks forecast accuracy and recommends adjustments.
• Creates schedules aligned with forecasted volumes.
• Manages schedule changes and rotation activities.
• Monitors real-time workload queue performance and staffing levels.
• Prepares productivity and performance reports.
• Conducts root-cause analysis for service level misses or staffing issues.
• Improves workflows through automation and reporting enhancements.