L.A. Care Health Plan

Director

• Develops, and implements standards, quality gates and governance frameworks.
• Ensures that the core system configuration is executed with rigor, transparency, and precision.
• Strengthens upstream quality and operational readiness by leading disciplined change processes, anticipating downstream impacts, and establishing a consistent framework that reduces defects, improves accuracy, and enhances the reliability of the claims environment.
• Oversees the end-to-end configuration life cycle including analysis, requirements validation, design, build, testing, migration, and post-deployment monitoring.
• Establishes standardized processes, documentation requirements, and quality gates to ensure accuracy, traceability, and reliable execution of configuration changes.
• Ensures configuration solutions support accurate adjudication and align with operational needs, regulatory requirements, and enterprise readiness.
• Collaborates with cross functional teams on configuration priorities, impacts, and implementation timelines.
• Tracks and trends configuration errors, collaborating on remediation planning, systemic improvements, and prevention strategies.

Director, Configuration

• Defines the payment integrity operating model and is accountable for prevention, governance, analytics, risk reduction, and sustained accuracy across all prepay and post pay activity.
• Responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program.
• Ensures the accuracy of provider payments, minimizes inappropriate spend, and strengthens preventive and detective controls across all lines of business.
• Partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.
• Oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, COB, TPL, and analytical review of billing and payment patterns.
• Develops strategic plans, drives change, and influences critical business outcomes.

Director, Payment Integrity

QA Engineer

• Responsible for leading the quality, compliance, training, and continuous improvement functions.
• Builds a disciplined quality framework that strengthens upstream and downstream controls, enhances first-pass accuracy, and reduces defects.
• Oversees enterprise claims quality auditing, claims compliance oversight, issue detection and validation, and corrective action planning.
• Ensures the organization meets federal, state, and contractual requirements by maintaining effective monitoring, quality review programs, compliance validation, and documentation standards.
• Leads training and policy interpretation for claims-related operations.
• Serves as the primary partner to operational leaders on quality and compliance matters.
• Builds a high-performing team and fosters a culture of quality, operational rigor, accountability, and continuous improvement.

Director – Center of Excellence and Quality Assurance

Administration

• Govern enterprise outcomes and risk controls in claims administration
• Lead end-to-end claims ecosystem including adjudication and adjustments
• Ensure compliance and accuracy across all lines of business
• Monitor production performance to meet regulatory compliance
• Develop strategic plans and influence business outcomes
• Foster a culture of accountability and continuous improvement

Director, Claims Administration

Manager

• Manages all adjustment-related operational workflows, including provider disputes, escalated claim reviews, complex adjustments, and litigation-related claim support.
• Ensures that adjustment decisions are accurate, timely, consistent, and fully compliant with state, federal, and contractual requirements.
• Functions as the operational leader for all claim adjustments that exceed routine examiner responsibilities and require higher-level investigation or coordination.
• Leads a team of adjustment analysts and dispute specialists, building a culture of accuracy, documentation discipline, transparency, and initiative-taking issue identification.
• Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures.

Senior Manager, Claims Adjustments

Operations

• Manages and leads critical components of L.A. Care’s enterprise Payment Integrity program
• Oversees the design, execution, and continuous refinement of pre-payment and post-payment accuracy activities
• Ensures PI programs are executed consistently, documented clearly, and aligned with regulatory, contractual, and financial expectations
• Leads daily operations of pre-pay and post-pay PI activities, ensuring accuracy, timeliness, and effective case management
• Oversees prospective review programs including clinical editing, code auditing, algorithm-driven controls, and provider contract/benefit interpretation
• Ensures post-pay functions, including data mining, recovery validation, provider outreach, and reconciliation, are accurate, transparent, and compliant
• Establishes standardized workflows, documentation, and quality review expectations across all PI teams.
• Oversees identification and validation of overpayments and underpayments from solicited/unsolicited sources, analytics, and vendor partners
• Partners with key stakeholders to implement upstream corrections and reduce recurring defects
• Ensures operational execution of vendor-driven PI programs, ensuring strong Service level agreement (SLA) performance, validated results, and accurate financial reporting.

Senior Manager, Payment Integrity Operations

• Provides daily operational leadership for enterprise claims adjudication across all lines of business.
• Responsible for ensuring timely, accurate, compliant claim processing through disciplined production management, strong operational controls, and consistent application of claims policies, benefit rules, and contractual requirements.
• Manages a team to deliver predictable throughput, high first-pass accuracy, strong auto-adjudication rates, and consistent cycle-time performance.
• Ensures operational readiness for benefit changes, system updates, regulatory modifications, and cross-functional dependencies while continuously improving process quality and reducing rework.
• Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures.

Senior Manager, Claims Administration

Compliance

• Ensures that Core Administrative Operations has a strong and sustainable compliance foundation.
• Interprets regulatory guidance, identifies compliance risks, develops training that operationalizes regulatory changes, and builds documentation that ensures accuracy and audit readiness.
• Strengthens operational integrity, improves adherence to state/federal requirements, and equips staff with the knowledge and tools needed to process claims accurately and consistently.
• Monitors compliance with regulatory agencies, NCQA, and contractual requirements related to claims processing, adjustments, disputes, configuration, and payment accuracy.
• Oversees compliance monitoring and internal validation activities to ensure critical regulations are consistently met.
• Serves as subject-matter expert on regulatory and contractual requirements affecting claims and related administrative functions.
• Designs, implements, and oversees comprehensive operational training programs across cross functional teams.
• Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards.

Manager, Claims Compliance

• Responsible for leading and optimizing L.A. Care’s core administrative functions
• Ensures standardized, efficient, accurate, and compliant administrative operations
• Steers top-level decision-making and implements initiatives that drive organization forward
• Drives modernization, operational maturity, and continuous improvement
• Oversees a diverse team, ensuring talent development, performance management

Senior Director, Core Administrative Operations

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 such as benefit misinterpretations, incomplete disclosures, or policy deviations.
• Prepares detailed audit reports summarizing findings, trends, error types, and opportunities for improvement.
• Tracks performance results at the individual, team, and process level.
• Presents audit insights to leadership.
• Participates in Root Cause Analysis (RCA) for recurring quality issues, compliance gaps, or service failures.
• Collaborates with internal teams to develop and implement corrective actions.

Customer Engagement and Experience Compliance and Quality Auditor II

• Managing and leading the operational quality program focused on preventative and predictive orientation that evaluates and strengthens accuracy across the entire claims lifecycle
• Ensuring L.A. Care’s Core Administrative Operations maintain high processing accuracy, strong control points, and consistent application of benefits, provider contracts, coding standards, and regulatory requirements
• Overseeing operational QA testing, examiner-level audit programs, quality scoring, root-cause identification, and corrective action validation
• Supporting regulatory readiness through mock audit participation, audit universe/sample creation, and quality documentation preparation
• Managing staff and partnering closely with cross functional key stakeholders to drive upstream improvements
• Monitoring and validating adjustment processing, provider disputes resolutions, and post-payment quality outcomes tied to Payment Integrity remediation.

Manager, Claims Quality Assurance

Project Manager

• Manage, assess and execute strategies based on identified stakeholder needs
• Oversee the department's outreach and engagement projects aligned with organizational strategic goals
• Create project documentation and workflows
• Manage interdepartmental traffic/requests for CE&E department project support
• Develop and maintain a master calendar of CE&E projects, activities and regulatory timeframes
• Participate in the development, monitoring, and up keep of all Desk Level Procedures and Policies and Procedures
• Document project/program and business workflows and processes

Customer Engagement and Experience Project Manager II

• Manages L.A. Care’s specialized “Tiger Team” responsible for investigating, reconstructing, quantifying, and remediating the most complex and high-risk claims issues across the enterprise.
• Ensures that investigations are comprehensive, evidence-based, and defensible, and that remediation actions are accurate, auditable, and sustainable.
• Drives L.A. Care’s most critical investigative and corrective work.
• Partners with Legal to support litigation research, discovery preparation, and exposure modeling.
• Oversees multi-layered remediation for retroactive benefit changes, contract corrections, reimbursement updates, or operational/system defects.
• Ensures remediation execution is compliant, accurate, documented, and coordinated with cross-functional key stakeholders.
• Provides operational insights and documentation required for regulators, external auditors, and legal proceedings.

Manager, Claims Research and Remediation

Data Analyst

• Serve as a Subject Matter expert (SME), technical and analytic integrator
• Responsible for designing, developing, and operationalizing advanced analytic solutions
• Transform complex, multi-domain data into interpretable and actionable insights
• Develop insight rich, production ready analytic assets
• Deliver repeatable, governed analyses that illuminate key drivers of care quality, efficiency, and financial outcomes
• Design and maintain reusable analytic data models and ETL pipelines
• Lead development of advanced dashboards, reports, and analytic tools
• Partner with analysts, data scientists, and operational stakeholders
• Ensure adherence to data lineage, governance, and reproducibility standards
• Support enterprise level measure refresh cycles
• Translate analytic findings into business relevant narratives

Data Analyst III

• The Enterprise Data Analyst III serves as a Subject Matter Expert (SME) contributor responsible for leading complex analytic projects that link insights directly to enterprise goals, resource allocation, and performance improvement.
• Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights.
• Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards.
• Consults across business operations, providing mentorship, and contributing specialized knowledge.
• Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.