SCAN

QA Engineer

• Responsible for developing and implementing a quality assurance program, reviewing audits meet accuracy, timeless and contractual obligations, and enhancing operational processes.
• Partner with Ops leadership to design and develop an effective Quality Assurance and Compliance program gaining alignment on methodology, audit approach, KPIs, standards and issue resolution process
• Manage quality and Compliance reporting.
• Coordinate accurate and timely submission of data, including audit readiness and documentation standards for Operations
• Collaborate with operational partners to align workflows, address barriers to performance, and implement initiatives to enhance operations and member satisfaction.
• Monitor and communicate performance trends track and analyze key performance indicators (KPIs).
• Share actionable insights and recommendations with senior leadership to inform strategic planning and resource allocation.
• Establish effective governance framework to include Audit the Auditor mechanism to achieve organizational goals related to quality and compliance.
• Lead a team of quality assurance and compliance professionals mentoring, fostering positive team culture, promote leadership growth, encourage innovation, and continuous learning to achieve team or individual goals
• Identifying trend and areas of opportunity for process improvements and additional training
• Work closely with operations leadership to review finding, develop action plans and remediate issues
• Partner with operational leadership to review finding, develop corrective action plans, and remediate identified issues to the root cause ensuring a closed loop process
• Monitor industry trends, regulatory changes and current events to ensure team remains informed and adapts to evolving policies and procedures.
• Supervises/Manages Others (i.e. hires, performance reviews, corrective action, etc.)
• Actively support the achievement of SCAN’s Vision and Goals.

Senior Manager, Quality Assurance, Compliance

Analyst

• Monitor, analyze, and develop insights on STAR measure performance for HEDIS, CAHPS, HOS, Pharmacy (PQA), and Operational measures.
• Perform root-cause analysis to identify drivers of performance gaps and recommend targeted interventions.
• Partner with Health Care Informatics and other internal analytics team to ensure dashboards, scorecards, and routine performance reports for leadership and operational partners.
• Model future projections and perform “What-if” scenarios for STAR rating forecasts.
• Conduct routine process analysis for department’s operating procedures and validate compliance with regulatory requirements or develop details assessment outlining gaps/risks identified with proposed process redesigns to mitigate identified gaps and risks.
• Collaborate with internal teams (Clinical Operations, Pharmacy, Member Experience, Network, Provider Relations) to design and implement quality improvement strategies.
• Track performance of interventions and provide data-driven insights on progress and effectiveness.
• Conduct Star competitor analysis and develop insights for all SCAN markets, potential partnerships, or growth opportunities.
• Work with IT and data teams to enhance data infrastructure and ensure data quality for STAR reports, and troubleshoot data discrepancies.
• Support the design and evaluation of interventions aimed at improving provider performance, member satisfaction, and clinical outcomes.

Senior Quality Analyst

Account Executive

• Responsible for the oversight, training and servicing of the broker distribution channel in the assigned market aiming to position our health plan for sales achievement and success.
• Achieve all broker sales targets.
• Maintain business relationships with brokers, general agency representatives and ancillary stakeholders by providing outstanding service to all in assigned territory.
• Expand the broker sales distribution channel by identifying, training and certifying new agencies and brokers.
• Monitor broker quality; resolve issues to ensure high-quality representation of SCAN.
• Provide reporting on new business opportunities, issues encountered in the field with respect to network, claims, customer service, marketing, etc.
• Work closely with marketing staff to implement and execute on broker cooperative marketing campaigns.

Broker Account Executive – Central California

Manager

• Executes programs that meet the needs of the organization or its employees or customers.
• Participates in all aspects of corporate programs, including planning, budgeting, staffing, and performance.
• Promotes the program throughout the organization and tracks utilization.
• Supervises the work of program or project staff to ensure that work in completed on time or in accordance with established standards or specifications.
• Evaluates program effectiveness by collecting and analyzing data in support of key performance metrics.
• Ensures that activities are in compliance with organizational policies and any relevant external regulations.
• Provides reports and updates to senior management or other stakeholders.
• Serves as leader of authority with expert-level knowledge in one or more areas.
• Makes authoritative decisions and recommendations.
• Plans, organizes, and guides projects and subordinate employees.
• May be called on to consult in other areas.
• Responsible for defining the vision, scope, and objectives of program and encompass multiple related projects.
• Maintain communications between stakeholders, sponsors, and team members.

Senior Manager, STAR Quality

• Analyze frontline performance and experience data to identify trends, pain points, and improvement opportunities.
• Gather and synthesize Rebel (frontline) feedback through surveys, QA data, and voice-of-employee inputs.
• Support frontline experience initiatives that improve day-to-day work conditions and service delivery.
• Translate QA and performance insights into actionable recommendations for coaching and development.
• Partner with HR and Operations to support career pathing and promotion readiness using data-driven insights.
• Evaluate training and onboarding effectiveness and identify gaps aligned to role expectations.
• Execute and support the Voice of Employee program, including reporting and action planning.
• Coordinate cross-functional improvement projects impacting frontline experience and member.

Experience Analyst

Bilingual

• Provide long-term care management to frail, economically disadvantaged, culturally diverse older adults, disabled adults and caregivers in order to help them remain safely at home and to prevent premature institutionalization
• Assess new clients and determine appropriateness for the MSSP program, certify the client as nursing home eligible, conduct assessments and reassessments for identification of client’s medical, physical, and psychological needs
• Ensure client’s needs are met through written care plan approved by the program supervisor and discussed verbally with the client and/or his representative
• Provide ongoing health education to non-clinical staff members
• Present cases at and participates in weekly team case conference per guidelines
• Discuss during case conference complex health care issues for teaching purposes
• Contact client’s physician as needed to discuss health problems identified during assessments
• Provide education to the client or family member regarding topics including self-care, hygiene, and nutrition
• Collaborate with staff, clients, physicians, home health, community services, family members, hospital discharge planners, and other professionals involved in the care of the client to assure appropriate services, and safe living environment below the cost of a skilled nursing facility
• Maintain monthly documentation of clients along with other clinical documentation of relevant contacts with clients, service providers, health professionals, or other community agencies in a timely manner
• Maintain accurate purchase of service records by completing accurate and timely monthly service authorizations and verifications to contracted vendors and following contract guidelines for service expenditures
• Develop and implement care plans for assigned caseload
• Help to maintain census and provide excellent customer service in the community by participating in ongoing outreach activities
• Participate regularly in Quality Assurance chart reviews, completing other audits as required, helping to train new employees, participating in training sessions, and responding positively to suggestions for improvement
• Increase knowledge by keeping current on Medicare and Medi-Cal policies, Federal and State legislation affecting health and social services, maintaining updated community resource information, attending trainings as scheduled, actively participating in supervision, and striving to improve professionally
• Other duties as assigned.

Bilingual Spanish Nurse Care Planner – RN

• Contribute to the overall success of IAH through increasing education and awareness of IAH programs, community outreach and special events, and handling incoming calls.
• Support operations through outreach calls to clients when needed to enhance continuity of care.
• Support program operations by answering incoming community calls and providing program eligibility information
• Record information obtained from all interactions into electronic documentation (on a monthly task list and, when needed, on a tracking spreadsheet)
• Perform intake functions that include conducting initial interviews, gathering pertinent information, assessing urgency of the need, and providing overall program information
• Maintain the member‘s right to privacy and protect SCAN operations by keeping information confidential
• Inform the community and potential clients about IAH services utilizing approved presentation materials
• Identify and maintain a guide of community resources This includes leading presentations, group and one-to-one meetings, and responding to incoming phone calls
• Contribute to team effort by accomplishing related results as needed
• Represent IAH at local events involving older adults, such as health fairs, educational events, community-based organization events, senior expos, etc
• Supports IAH operations through outreach calls to clients
• Establish, develop and cultivate relationships in the communities IAH serves
• Identify new and relevant organizations to approach, initiate contact, and work to build partnerships and relationships
• Educate and communicate to external audiences about IAH
• Assist with ad-hoc projects and client follow up calls, as directed
• Communicate with respective program supervisor on intakes, wait lists and enrollment goals

Bilingual Resource Specialist

• Provide long-term care management to frail, economically disadvantaged, culturally diverse older adults, disabled adults and caregivers in order to help them remain safely at home and to prevent premature institutionalization.
• Conduct in home and telephonic assessments, care planning, and client monitoring through contacts with the client, professionals and client’s support system.
• Coordinate linkages with community-based services and resources.
• Maintain legal and clinical written record of each client’s case by completing all necessary documentation (including assessment, care plans, service arrangements and client monitoring progress notes) in a timely manner.
• Ensure timely implementation of services for clients by completing all work within required timeframes.
• Address client’s needs by developing and implementing a comprehensive care plan specific to client’s objectives and goals, with a plan for resolution within a measurable time frame and appropriate interventions outlined.
• Ensure coordination of services and continuity of care by maintaining on-going documentation of contacts with client, family and caregivers, service providers, health professionals, and others connected to the client’s care.
• Maintain effective communication with the other disciplines working with client, provide feedback on the psychosocial aspects of a client’s situation and offer informal training to fellow care planners and staff in other disciplines.
• Maintain accurate purchase of service records by completing accurate and timely monthly service authorizations and verifications to contracted vendors and following contract guidelines for service expenditures.
• Increase knowledge of care planner functions, by keeping current on Medicare and Medi-Cal policies, Federal and State legislation affecting health and social services, maintaining updated community resource information, attending trainings as scheduled, actively participating in supervision, and striving to improve professionally.
• Help to maintain census and provide excellent customer service in the community by participating in ongoing outreach activities.
• Participate regularly in Case Conference, Quality Assurance chart reviews, completing other audits as required, helping to train new employees, participating in training sessions, and responding positively to suggestions for improvement.

Bilingual Spanish Care Manager

• Coordinate care for members in collaboration with the Integrated Care Team, ensuring members are directed to the optimal facility for their needs and have all necessary services, supplies, and information.
• Authorizes services based on well-developed knowledge and skills in areas of utilization management, medical necessity, and patient status determination.
• Conduct pre-service and concurrent review following established guidelines.
• Applies care management principles and practices to ensure medical needs, care, and service are coordinated.
• Serve as point of person to speak with patients, family members, and providers to address concerns pertaining to care, transfers and authorizations.
• Review patient’s clinical information and authorize requested medical services in a timely manner.
• Ensure necessary inpatient and outpatient care or other services are rendered to SCAN members at the right time, the right level of care and at the right location while adhering to all policies and procedures.
• Issue determinations within required regulatory timeframes.
• Apply evidenced-based criteria and guidelines as well as clinical judgment and expertise to assess treatment plans.
• Manage member medical cases by applying the essential activities of care management and utilization management including assessment, planning, implementation, coordination, advocating, monitoring, and evaluation.
• Refer cases that do not meet established criteria to the Integrated Care physicians for secondary review.
• Review all acute/skilled nursing appeals and create detail explanation of non-coverage and reinstatement letters.
• Prepare, participate and facilitate high risk huddles and skilled nursing rounds.
• Maintain a list of high risk patients and conduct regular outreach calls to check on their health status.
• Coordinate timely delivery of last day cover letters to skilled nursing facilities.
• Coordinate discharge needs from inpatient acute settings and skilled nursing facilities as appropriate for each member.
• Review tasks assigned by Integrated Care Nurse Practitioners and coordinate member care accordingly, including services such as: home health; DME ordering, wound care, Foley catheter, Enteral, colostomy supplies, infusion orders and outpatient services.
• Coordinate direct admissions to skilled nursing facilities and direct ER transfers from senior living communities.
• Develop effective working relationships and provide clinical guidance to Care Coordinators on clinical matters.
• Demonstrate excellent organizational, decision-making and multi-tasking skills as demonstrated by problem solving and successful outcomes.
• Promote the mission, vision, and values of SCAN Health Plan and serve as an ambassador when interfacing with external stakeholders.
• Actively support the achievement of SCAN’s Vision and Goals.