SCAN

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.
• 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

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.

Care Manager – LVN

Learning and Development

• Lead Training Program Design and Development: Lead the design and development of training programs that align with company goals, strategic initiatives, and regulatory requirements.
• Create and update advanced training materials, including manuals, presentations, and online modules, to ensure they are current, relevant, and engaging.
• Deliver and Facilitate Training Sessions: Lead and facilitate training sessions for new and existing employees, covering a wide range of topics such as company policies, procedures, and specific job functions.
• Use a variety of training methods, including classroom instruction, online training, and hands-on demonstrations, to cater to different learning styles and ensure maximum retention.
• Evaluate and Enhance Training Effectiveness: Conduct comprehensive evaluations of training programs to assess their effectiveness and impact on employee performance.
• Develop and implement advanced strategies to improve training content, delivery methods, and overall program outcomes based on performance metrics and feedback.
• Analyze training data to identify trends and areas for improvement.
• Manage Training Records and Compliance: Oversee the maintenance of detailed and accurate records of training sessions, including attendance, completion, and performance data.
• Ensure all training documentation is compliant with company and regulatory standards.
• Generate and present reports on training metrics to senior management and other stakeholders.
• Lead Special Projects and Initiatives: Lead the planning and execution of special training projects and initiatives, including the development of new training programs and the implementation of existing ones.
• Collaborate with cross-functional teams to support the rollout of new processes, systems, and policies.
• Stay Updated on Industry Trends and Best Practices: Continuously research and stay informed about new training methodologies, industry best practices, and changes in healthcare regulations and standards.
• Apply this knowledge to enhance the quality and effectiveness of training programs.
• Recommend and implement new training technologies and tools to improve the learning experience.
• Mentor and Coach Junior Training Specialists: Provide guidance, mentorship, and coaching to junior training specialists to help them develop their skills and knowledge.
• Conduct performance evaluations and provide constructive feedback to support their professional growth.
• Develop and Maintain Training Standards: Establish and maintain high standards for training programs and materials.
• Develop and implement training policies and procedures to ensure consistency and quality across all training initiatives.

Senior Training Specialist

• Manages programs and clinicians providing primary care to SCAN members within the integrated care delivery model at SCAN.
• Manages the performance of clinical teams to achieve defined clinical care outcomes.
• Oversees clinicians in daily operations, ensuring adherence to ethics and quality standards in the delivery of patient care by Advanced Practice Providers (AAP).
• Selects, on-boards, trains and develops clinicians within the integrated care delivery model.
• Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating and enforcing systems, policies, and procedures.
• Provides clinical care to include performing exams, ordering diagnostic and screening tests, developing plans of care, accurately documenting patient medical history and care, and educating and consulting with patients and families.
• Collaborates with senior management on the resolution of operational and performance issues and the development of new plans and programs.
• Improves and integrates APP functions and systems across specialties and departments, including the development and implementation of APP Best Practice Models.
• Develops and monitors success metrics and adjusts programs as needed to improve efficiencies and effectiveness.
• Networks and builds relationships with internal and external key stakeholders to promote membership growth and quality outcomes for integrated care delivery products.

Manager, Nurse Practitioner

• Serves members by being an advocate and point of contact for member questions and concerns regarding benefits, eligibility, referrals, claims and any other aspects of plan benefits and services.
• Ensures member satisfaction by providing superior customer service and willingness to help at all times while maintaining a professional demeanor.
• Provides quality customer service by applying SCAN Five Service Principles.
• Educates members, family, providers and caregivers regarding benefits and plan options.
• Accurately explains benefits and plan options in person, via email or telephonically.
• Provides follow-up with members by clarifying the customer’s issue, determining the cause, and identifying and explaining the solution.
• Escalates appropriate member issues to management or other departments as required.
• Consistently meets and/or exceeds the departmental standards, including, but not limited to: quality, productivity, and adherence to schedule and attendance.
• Responds appropriately and in a timely fashion to member/internal staff/providers by answering telephonic and written inquiries concerning benefits, eligibility, referrals, claims and all other issues following departmental policies and procedures and job aids.
• Takes ownership of the issue, focusing on providing solutions and options for members, as necessary through resolution of member issues.
• Increases member satisfaction by following up and resolving member issues, complaints, and questions in an efficient, timely and accurate fashion; coordinates resolution with providers and other departments as needed.

SAL Advocate – Bilingual

Director

• Leverage advanced analytics, AI, and reporting to drive SCAN’s clinical insights and innovation.
• Build scalable AI/analytics products that improve clinical outcomes, operational performance, affordability, and regulatory readiness.
• Own the clinical analytics strategy and agenda, setting roadmap and prioritization in partnership with clinical, pharmacy, and compliance leaders.
• Drive member risk stratification and predictive analytics, including development and deployment of models that identify emerging high-risk members.
• Serve as a thought leader on practical GenAI adoption to improve clinical and economic outcomes and ClinOps efficiency.
• Translate predictive insights into action by partnering with UM/CM and clinical leaders to design intervention pathways.
• Lead clinical operations excellence analytics across UM/CM/medical policy.
• Own the design and evolution of a clinical insights semantic layer that standardizes key clinical/UM/Rx concepts across domains.
• Provide targeted analytics support for care delivery assets, ensuring alignment with enterprise measurement standards.
• Own Part C compliance analytics and reporting readiness, partnering with Compliance and clinical operations.
• Oversee pharmacy analytics and data management, ensuring reliable Rx data pipelines, reconciliation logic, and reporting accuracy.
• Support clinical and Rx competitive intelligence including market trend monitoring, emerging specialty categories.

Director, Clinical Intelligence

Business Analyst

• Gather and analyze data from various sources to identify trends, patterns, and insights that can inform business decisions.
• Work closely with stakeholders, including managers, team members, and clients, to understand and document business needs, requirements and user stories.
• Identify inefficiencies and areas for improvement in existing business processes.
• Create and maintain detailed reports, documentation, and presentations to communicate findings and recommendations to stakeholders.
• Facilitate communication between different departments and stakeholders to ensure alignment and clarity on project goals and progress.
• Help develop and deliver communications, user guides and training to promote adoption and utilization.
• Utilize data to gather insights, assess performance, and identify gaps; Help define and implement solutions to address gaps, improve performance and elevate business outcomes.

Product Manager

• Lead the development of pharmacy products, including service area expansion and submission to CMS, ensuring alignment with regulatory requirements, market needs, and organizational objectives.
• Collaborate with internal & external stakeholders including pharmacists, PBMs, developers, compliance teams, and marketing to gather requirements, prioritize features, and ensure successful implementation of pharmacy initiatives.
• Collaborate with data analytics teams to conduct prescription benefit market analysis, evaluate competitors offerings per each service area and identify industry trends to generate product enhancements.
• Monitor and analyze product performance, including utilization trends, financial impact and member experience, identifying opportunities for improvement.
• Support operational readiness for Annual Enrollment Period (AEP) and product launches, including production of the pharmacy-related customized communication and marketing materials.
• Perform AEP staff training and cross-functional alignment.
• Support RFP process, including evaluation criteria, to optimize pharmacy benefit operations, financial performance, and member experience.
• Contribute to the development and maintenance of policies, procedures, and training materials.
• Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Serve as a subject matter expert on pharmacy products and benefits, supporting cross-functional teams during CMS and state regulatory audits, including CMS Part C and D Data Validation audits.
• Prepare presentations and updates to leadership regarding product performance, upcoming initiatives, and regulatory changes.
• Ensure products meet HIPAA, FDA, CMS, and other pharmacy-related regulatory standards.
• Maintain current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.
• Serve as the subject matter expert on the Inflation Reduction Act’s Medicare Part D provisions, CMMI initiatives and Medicare Prescription Payment Plan.
• Foster strong relationships with PBM partners to align on product implementation, service delivery, and continuous improvement initiatives.
• Participate in the annual BID cycle development process.

Pharmacy Product Manager

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
• Actively support the achievement of SCAN’s Vision and Goals

Senior Quality Analyst – STARS

• Provide long-term care management to frail, economically disadvantaged, culturally diverse older adults, disabled adults and caregivers.
• Conduct in home and telephonic assessments, care planning, and client monitoring.
• Coordinate linkages with community-based services and resources.
• Maintain legal and clinical written record of each client’s case.
• 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.
• Ensure coordination of services and continuity of care by maintaining ongoing documentation.
• Maintain effective communication with other disciplines working with clients.
• Increase knowledge of care planner functions and actively participate in supervision.

Bilingual Spanish Care Manager – Temp

• Supports daily operational functions and oversight of the SCAN Pharmacy Benefit Management (PBM) company on delegated Part D activities
• Assists with maintaining compliance with Part D deadlines and regulatory timeframes
• Provides support in managing Eligibility files, Prescription Drug Event (PDE) data, Drug Plan Finder submissions, Financial Information Reporting, and other key functions to help ensure adherence to Medicare requirements
• Serves as a subject matter expert for Part D Reporting requirements, Pharmacy Access Requirements, Prescription Drug Event data, Financial Information Reporting and Drug Plan Finder files by keeping up to date with Medicare requirements
• Ensures eligibility and coordination of benefit files are sent to the PBM for processing and assesses if file enhancements are needed
• Ensures the PBM is processing Prescription Drug Events, Automated Claims Reprocessing and Financial Information Data according to CMS regulatory standards by conducting daily oversight
• Ensures PBM oversight of claims adjudication and retrolics and ensures 1/1 Readiness related to eligibility
• Analyzes and monitors large data sets that are exchanged from SCAN to the PBM using a variety of reporting tools
• Ensures audit documentation is prepared according to audit instructions and provided within the specified audit time frame
• Prepares written responses or documentation for pharmacy audits
• Performs routine monitoring to ensure Part D compliance and detect performance issues or operational gaps
• Assists in the implementation, testing, and validation of pharmacy benefits to ensure accurate benefit configuration and claims adjudication
• Collaborates with cross-functional teams, including Compliance, Product, and IT, to address issues and support PDE and other pharmacy initiatives
• Identifies and escalates issues related to pharmacy benefits, claims processing, and PDE submissions, working with the PBM and internal teams to resolve discrepancies
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications & CMS regulatory requirements; establishing personal networks; participating in professional societies
• Contributes to the development, maintenance, and documentation of standard operating procedures (SOPs) and desktop procedures to support compliance and operational efficiency.

Pharmacy Analyst I

Business Development Rep

• Works closely with career field representatives and external brokers to develop/maintain/deepen relationships with key business leaders, community-based organizations (CBOs), and providers, ensuring all efforts are directed towards building membership for SCAN Health Plan.
• Responsible for achieving monthly, quarterly, and annual enrollment goals established by management by transitioning leads to enrollments.
• Responsible for following up with reps and brokers for lead data and tracking sales conversions.
• Meets or exceeds weekly and monthly qualified lead goals.
• Helps local market achieve monthly sales goals; works with direct sales teams in lead development and public facing presentations (advertised or non-advertised).
• Distributes approved marketing and event materials.
• Works with Corporate Marketing and Compliance Departments in the approval, development, and production of advertising materials and or invitations for events.
• Locates, plans, sets-up, attends and presents at Quarterly New Member Orientations and year-round Education events (as needed in a non-virtual event) in the local community.
• Provides monthly calendar of their planned activities and ensures that all scheduled events filed. Minimum 20 events per month.
• Maintains weekly summary of activity and submits report on a weekly basis.
• Actively engages with provider marketing events, engages with primary care physicians and front offices.
• Responsible for carrying out events and achieving assigned membership growth targets through direct and indirect marketing activities.
• Works collaboratively with all sales channels to improve enrollment.
• Schedules, coordinates, participates in enrollment events, encourages vital partners to participate, and assists where feasible.
• Schedule new member orientations and present materials (plan benefits and other important information) to new members with a goal of retention and connecting new members to SCAN services.
• Ensures all events, activities, communication, materials, media, promotions, etc., meet brand and corporate guidelines and CMS rules and regulations.
• Responsible for obtaining payment approval for community events, communicating and paying vendor.
• Adhering to the highest level of compliance expectations.
• Adhering to all sales operations processes.
• Knowing all elements of the product portfolio and associated eligibility guidelines for various election periods.
• Actively support the achievement of SCAN’s Vision and Goals.

Community Business Development Representative

Customer Support

• Provide excellent customer service to our contracted brokers and SCAN Sales Representatives that call into the Sales Support line.
• Answer phone calls from internal sales representatives as well as external broker agents.
• Responds to questions regarding eligibility, network, formulary, benefit design, commissions, as well as related topics or concerns.
• Accurately interpret and explain benefits and plan options.
• Provide follow-up to callers as needed to resolve the inquiry, in a timely fashion.
• Escalate appropriate issues to management, and route calls to internal departments when needed.
• Maintain professional knowledge of Medicare and SCAN benefits by successfully completing required training.
• Follow all state and regularity guidelines by adhering to programs implemented by Compliance Department.
• Document all calls and action items in the Sales Support call log, according to department standards.
• Contribute to team effort by accomplishing related results as needed.

Sales Support Representative

Operations

• Ensure regulatory compliance with respect to prescription benefits set up and year-round CMS Program Audit, 1/3 Financial audit, National MEDIC, and other audits readiness;
• Provide leadership and support during all CMS Regulatory Audits related to pharmacy operations;
• Ensure accuracy of written responses and/or documentation for the pharmacy audits;
• Prepare written responses or documentation for pharmacy audits.
• Serve as a subject matter expert for Part D Reporting requirements.
• Maintain current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance.
• Oversee the accurate implementation and maintenance of pharmacy benefits.
• Lead automation efforts related to the Prescription Drug Event, Benefits Configuration and Testing Initiatives.
• Prepare documentation for Service Area Expansion application submission to CMS.
• Collaborate with other SCAN departments by participating in cross-functional meetings.

Manager, Pharmacy Operations

Data Analyst

• Conducts monthly and quarterly financial reconciliations, reviewing account activity and resolving discrepancies to maintain accurate financial records.
• Reconciles data across financial, billing, and operational systems to ensure completeness, consistency, and alignment of key datasets.
• Maintains and enhances the billing module by updating logic, troubleshooting issues, and supporting automation using Alteryx, SQL, and advanced Excel/VBA.
• Completes daily and monthly cash reconciliations by matching bank activity to system postings and resolving unapplied or unidentified payments.
• Performs detailed revenue reconciliations, validating billed, recognized, and collected revenue and supporting month-end close activities.
• Monitors data quality across financial processes by implementing reconciliation controls, documenting workflows, and ensuring audit readiness.
• Collaborates with Finance, RCM, IT, and Operations to resolve issues, validate system changes, and improve end-to-end financial and billing workflows.