Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Bachelor’s degree in Healthcare Administration, Public Health, Business Administration, or a related field.

Preferred: Master’s degree (MSN, MBA, MHA, MPH) or equivalent advanced education.

Experience 

Minimum: At least eight years of healthcare compliance or regulatory experience. Experience in California healthcare environment.

Preferred: Experience in California’s managed care, medical group, IPA, MSO, or health plan environment.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Professional certification (e.g., CHC – Certified in Healthcare Compliance) preferred.

Skills, Knowledge & Abilities

· Strong knowledge of California and federal healthcare regulations (e.g., NCQA, Knox-Keene/DMHC, HIPAA, Covered California, CMS)

· Ability to interpret regulations and health plan contracts and translate into operational processes 

· Excellent interpersonal skills, ability to develop relationships with stakeholders; a solutions-oriented collaborator 

· Strong analytical, organizational, and problem-solving skills 

· Experience managing audits, investigations, and compliance workflows 

· Ability to manage multiple priorities and deadlines in a fast-paced environment 

· Ability to work independently and provide detail oriented, precise and meticulously reviewed work product

· Effective communication and cross-functional collaboration skills

· Exhibits professional maturity, confidence and competence in daily business interactions

· High level of integrity, discretion, and professional judgment

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Primarily a sedentary, hybrid role involving computer-based work with occasional travel. Requires strong analytical thinking, attention to detail, and the ability to manage complex regulatory issues under deadlines in a fast-paced environment. Includes frequent interaction with internal teams and external stakeholders, as well as occasional lifting or moving equipment up to 15 pounds.

PAY RANGE

$95,000 - $125,000 / annually

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School diploma or equivalent. Graduation from an accredited vocational nursing program.

Preferred: Additional training or coursework in case management, utilization management, or care coordination.

Experience 

Minimum: At least two years of clinical experience as an LVN.

Preferred: Experience in concurrent review or inpatient utilization management. Experience working in a Managed Services Organization (MSO), IPA, or health plan. Experience with Medicare Advantage and Medi-Cal managed care populations. Experience using electronic medical records and care management systems. Experience coordinating post-acute services.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

CA LVN license and BLS Certification

Skills, Knowledge & Abilities

  • Knowledge of inpatient and post-acute care coordination processes
  • Understanding of utilization management and medical necessity principles
  • Knowledge of SNF, IRF, LTACH, home health, and hospice care settings
  • Ability to monitor patient progress and identify barriers to discharge
  • Strong clinical documentation and organizational skills
  • Ability to work independently and collaboratively
  • Strong communication and interpersonal skills
  • Ability to manage multiple cases simultaneously
  • Proficiency with electronic medical record and care management systems
  • Knowledge of managed care and healthcare delivery systems in California
  • Understanding of HIPAA and patient confidentiality requirements

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office, hospital, and/or community-based setting; may require standing/walking for extended periods during onsite rounds or facility visits. Frequent use of computer, phone, and video conferencing; prolonged sitting when performing documentation and reporting. Ability to travel locally to hospitals and post-acute facilities; occasional regional travel may be required. Ability to lift/move items up to approximately 20 pounds (e.g., laptop, files, work materials). Visual and auditory acuity required to review clinical documentation and communicate effectively with patients, families, and care teams.

PAY RANGE

$35.00 - $40.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS 

Education/Training

Minimum: High School Diploma or equivalent.

Preferred: Associate’s or Bachelor’s degree in Healthcare Administration, Business Administration, Compliance, or related field.

Experience 

Minimum: At least two years of healthcare administrative, claims, or compliance experience.

Preferred: Three or more years of managed care, MSO, IPA, or health plan experience. Experience supporting claims audits, delegated oversight, or regulatory reporting. Experience working with claims systems such as EZ Cap or similar platforms.

Certification(s)

Preferred: Certified Professional Compliance Officer (CPCO) or Certified in Healthcare Compliance (CHC)

Skills, Knowledge & Abilities 

· Knowledge of managed care claims processes and regulatory requirements.

· Knowledge of DMHC, CMS, DHCS, and health plan regulatory and compliance requirements.

· Knowledge of audit processes, regulatory reporting, and delegated oversight requirements.

· Strong organizational and documentation management skills.

· Excellent written and verbal communication skills. 

· Strong analytical and problem-solving skills.

· Proficiency in Microsoft Office Suite, including Word, Excel, and Access. 

· Familiarity with claims systems such as EZ Cap preferred. 

· Ability to maintain confidentiality and data integrity.

· Ability to manage multiple priorities and meet regulatory deadlines.

· Ability to work independently and collaboratively.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical  demands described here are represented by those that must be met by an   employee to successfully perform the essential functions of this job. Work   is primarily performed in an office or hybrid office environment and requires   prolonged sitting, computer use, and document review.

The role requires sustained attention to detail, organization, and   analytical thinking to ensure compliance and audit readiness. Occasional   lifting of materials up to approximately 10–20 pounds may be required. This role requires the ability to maintain confidentiality and professionalism   when handling sensitive claims and compliance information.

PAY RANGE

$28.85 - $33.65 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School Diploma or equivalent.

Preferred: Associate’s or Bachelor’s degree in Healthcare Administration, Business Administration, Compliance, or related field.

Experience 

Minimum: At least five years of managed care claims auditing, claims examiner, or claims quality control experience. Two years of experience as a Claims   Examiner or Claims Adjuster. 

Preferred: Experience in MSO, IPA, or health plan environment. Experience supporting delegated managed care and regulatory audits. Experience auditing   professional and institutional claims.

Certification(s)

Preferred: Certified Professional Coder (CPC), Certified   Professional Medical Auditor (CPMA), or Certified Professional Compliance Officer (CPCO)

Skills, Knowledge & Abilities

· Strong knowledge of managed care claims processing and audit methodologies.

· Knowledge of CPT, HCPCS, ICD-10, DRG, and reimbursement methodologies. 

· Knowledge of health plan contracts, fee schedules, and DOFR agreements. 

· Knowledge of DMHC, CMS, DHCS, and regulatory requirements.

· Strong analytical and problem-solving skills.

· Ability to interpret and apply complex regulatory and contractual requirements.

· Strong attention to detail and audit documentation skills.

· Excellent written and verbal communication skills. 

· Proficiency with claims systems such as EZ Cap and Microsoft Office applications. 

· Ability to work independently and meet audit   deadlines.

· Ability to maintain confidentiality and data integrity.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and document review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Light physical effort may be required, including lifting up to approximately 10 pounds and occasional bending, reaching, or filing. This role requires the ability to maintain confidentiality and professionalism when handling sensitive claims and compliance information.

PAY RANGE

$28.85 - $33.65 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Bachelor’s degree in Business Administration, Finance, Accounting, or related field.

Experience 

Minimum: 5+ years of experience in the healthcare industry, preferably managed care. Strong background in claims processing and claims auditing. Experience with reimbursement methodologies and financial reconciliation.

Preferred: Experience analyzing capitation,   stop-loss, and health plan payments. Prior work using EZ-Cap or similar   claims processing systems.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

None required; certifications in medical billing or healthcare finance are a plus.

Skills, Knowledge & Abilities

· Strong knowledge of current HCFA/DOC regulatory guidelines.

· Ability to interpret claims data, reimbursement rules, and contractual provisions.

· Proficiency in Microsoft Office (Word, Excel).

· Strong analytical, problem-solving, and investigative skills.

· Ability to communicate professionally with providers, payers, and internal departments.

· High level of accuracy, confidentiality, and attention to detail.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. The role involves primarily sedentary work with light physical effort, including occasionally lifting items up to 10 pounds as well as periodic bending, stooping, and reaching associated with filing tasks. Mentally, the position requires sustained concentration on detailed analytical work, the ability to manage multiple priorities under time-sensitive conditions, and strong problem-solving and decision-making capabilities. Work is performed in a standard office environment, though there may be occasional travel between office locations as operational needs arise.

PAY RANGE

$35.00 - $40.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School diploma or equivalent.

Preferred: Associate’s or Bachelor’s degree in Healthcare Administration, Business Administration, or related field.

Experience

Minimum: 2+ years of provider data management, credentialing, or healthcare administrative experience.

Preferred: Experience in MSO, IPA, or health plan environment.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Knowledge of provider data management and healthcare systems.

· Proficiency with provider management systems such as EZ Cap, EPIC, or similar.

· Strong attention to detail and accuracy.

· Strong organizational and communication skills.

· Ability to maintain confidentiality and data integrity.

· Ability to manage multiple tasks and meet deadlines.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. Work is primarily performed in a standard office or hybrid office environment and requires prolonged periods of sitting, frequent use of computers, telephones, and office equipment. The role requires sustained mental concentration, attention to detail, and the ability to review and verify credentialing documentation accurately. Occasional lifting or moving of materials up to approximately 15–20 pounds may be required. This role requires the ability to communicate effectively with providers, staff, and external partners, and to maintain confidentiality of sensitive credentialing information.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Coursework or training in healthcare administration, utilization management, or medical billing/coding.

Experience 

Minimum: 2+ years of medical office or healthcare administrative experience.

Preferred: 1+ years of Utilization Management experience.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Typing certificate demonstrating a minimum of 45 WPM

Skills, Knowledge & Abilities

· Knowledge of medical terminology and healthcare administrative processes.

· Working knowledge of CPT, HCPCS, and ICD-10 coding.

· Strong written and verbal communication skills.

· Ability to interpret benefit coverage and utilization management determinations.

· High attention to detail with strong proofreading and documentation accuracy.

· Ability to organize, prioritize, and manage multiple deadlines in a fast-paced environment.

· Proficiency with general computer applications and electronic health record systems.

· Ability to exercise sound judgment and make independent decisions within established guidelines.

· Demonstrated professionalism, dependability, and service-oriented mindset.

· Effective problem-solving and conflict-resolution skills.

· Ability to work collaboratively and maintain positive interdepartmental relationships.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position requires the ability to perform work primarily in a seated, office-based environment with frequent use of computers, phones, and other standard office equipment. The role involves occasional standing, walking, and light lifting (up to 20 pounds), as well as routine bending, reaching, and repetitive hand use for typing and documentation. The position also requires sustained concentration, attention to detail, effective time management, and the ability to exercise sound judgment while handling sensitive and confidential information. Work is performed in a medical or administrative office setting with minimal exposure to environmental hazards.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduate of an accredited Licensed Vocational Nursing program.

Preferred: Additional coursework in Case Management or Managed Care.

Experience 

Minimum: 2+ years of inpatient review experience in a managed care organization or healthcare facility.

Preferred: Experience in ambulatory case management and/or high-risk patient programs.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current State LVN License

Current BLS Certificate

Certified Case Manager (CCM) credential (preferred).

Skills, Knowledge & Abilities

· Strong knowledge of healthcare delivery, case management principles, and managed care operations.

· Proficiency in Microsoft Office (Word, Excel, Outlook, Access, PowerPoint).

· Ability to type at least 40 WPM with accuracy.

· Excellent communication, interpersonal, and customer-service skills.

· Ability to prioritize, problem-solve, and work independently with minimal supervision.

· Skilled in documentation, time management, and maintaining compliance with regulations.

· Ability to collaborate across multidisciplinary clinical teams.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role is primarily sedentary, with most time spent seated for computer work, documentation, and phone communication. Limited standing, walking, and occasional driving to clinical sites are required. The position may involve light physical tasks such as lifting up to 20 pounds, occasional bending, reaching, and climbing stairs throughout the day. The work requires strong analytical skills, attention to detail, emotional resilience when managing complex or high-risk cases, and the ability to multitask in a fast-paced environment. Work is performed mainly in a standard office setting with regular use of computers and office equipment, with occasional exposure to clinical environments such as hospitals, clinics, or skilled nursing facilities.

PAY RANGE

$35.00 - $40.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduate of an accredited Licensed Vocational Nursing program.

Preferred: Additional coursework in Case Management or Managed Care.

Experience 

Minimum: 2+ years of inpatient review experience with a managed care organization or healthcare facility.

Preferred: Experience in high-risk case management programs. Prior leadership or lead-level clinical coordination experience.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current State LVN License

Current BLS Certificate

Certified Case Manager (CCM) credential (preferred).

Skills, Knowledge & Abilities

· Strong clinical assessment and case management skills.

· Knowledge of managed care, healthcare regulations, and care coordination workflows.

· Effective verbal and written communication.

· Ability to maintain professionalism, confidentiality, and HIPAA compliance.

· Strong organizational, analytical, and multi-tasking abilities.

· Proficiency in Microsoft Office applications and electronic medical record systems.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role is primarily sedentary, with most time spent seated for computer work, documentation, and phone communication. Limited standing, walking, and occasional driving to clinical sites are required. The position may involve light physical tasks such as lifting up to 20 pounds, occasional bending, reaching, and climbing stairs throughout the day. The work requires strong analytical skills, attention to detail, emotional resilience when managing complex or high-risk cases, and the ability to multitask in a fast-paced environment. Work is performed mainly in a standard office setting with regular use of computers and office equipment, with occasional exposure to clinical environments such as hospitals, clinics, or skilled nursing facilities.

PAY RANGE

$35.00 - $40.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent required

Preferred: Associate’s degree or higher in healthcare administration, public health, social services, or related field. Certification as a Medical Assistant.

Experience 

Minimum: At least two years of experience in healthcare operations, quality improvement, medical office operations, care coordination, or managed care environment.

Preferred: Experience supporting HEDIS, CMS Star Ratings, or NCQA quality programs. Experience working in an MSO, IPA, or managed care   organization. Experience supporting Medicare Advantage, Medi-Cal, or commercial populations. Experience with medical record abstraction and quality reporting processes.

Certification(s)

Certified Professional in Healthcare Quality (CPHQ), Medical Assistant certification, or related healthcare certification preferred.

Skills, Knowledge   & Abilities

• Knowledge of HEDIS measures and preventive care quality standards preferred.
• Understanding of NCQA, CMS, DMHC, and health plan quality program requirements preferred.
• Knowledge of preventive care guidelines and population health principles.
• Proficiency in Microsoft Office applications, including Excel and PowerPoint.
• Ability to work with electronic health record systems and quality reporting tools.
• Strong organizational and tracking skills.
• Excellent verbal and written communication skills.
• Ability to educate and engage provider offices and interdisciplinary teams.
• Ability to establish and maintain effective working relationships.
• Strong attention to detail and data accuracy.
• Ability to manage multiple priorities and deadlines.
• Ability to work independently and collaboratively.
• Bilingual (Spanish or other threshold language) preferred.
• Knowledge of managed care and IPA environments preferred.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Primarily sedentary work involving prolonged computer use. Frequent standing, walking, and travel to provider offices may be required. Occasional lifting of up to 10 pounds may be necessary. Requires the ability to analyze performance data, maintain attention to detail, and communicate effectively. Work is performed in office, remote, and provider office environments, with frequent use of electronic systems and reporting tools.

PAY RANGE

$33.65 - $35.10 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduate of an accredited Licensed Vocational Nurse program.

Preferred: Coursework or training in quality management, managed care, compliance, or healthcare administration.

Experience     

Minimum: 10+ years of experience in Delegation Oversight, Medical Management, Utilization Management, Quality Management. Prior supervisory or leadership experience.

Preferred: Experience with HEDIS or quality performance measures. Experience in system testing, change control, or IT partnership environments. Advanced experience in reporting tools (SQL/BI), Excel, or healthcare analytics.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position. 

Certification(s)

Current State LVN License

Preferred: Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM), and/or Project Management Certification (CAPM/PMP).

Skills, Knowledge & Abilities

· Knowledge of delegated functions, compliance standards, and health plan reporting requirements. 

· Strong attention to detail and accuracy in documentation and letter review. 

· Ability to interpret guidelines and apply them within LVN scope to operational processes. 

· Proficiency in medical terminology, documentation standards, and regulatory timeframes. 

· Strong communication, teamwork, and stakeholder support skills. 

· Ability to coordinate tasks and support staff without independent clinical decision-making authority. 

· Competence in Microsoft Excel, reporting tools, and electronic workflows.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position involves prolonged computer-based work requiring frequent use of a keyboard and mouse, along with regular walking, standing, bending, and the ability to lift or move up to 25 pounds. It occasionally requires stooping, kneeling, crouching, or crawling. The role demands strong visual capability—including close, distance, color, peripheral vision, depth perception, and focus adjustment—and the ability to concentrate for extended periods while managing interruptions and meeting deadlines. Work is primarily remote but may involve travel for meetings or oversight activities.

PAY RANGE

$35.00 - $40.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Data Analytics, or related field.

Preferred: Master's degree in Healthcare Administration, Public Health, or related field.

Experience 

Minimum: 3+ years of Managed Care Eligibility & Benefits or healthcare administrative experience.

Preferred: Experience in managed care, MSO, IPA, or health plan settings; familiarity with member eligibility, eligibility files, and systems such as EZ-CAP.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Working knowledge of provider data structures, contract terms, and reimbursement methodologies (e.g. Medicare, carve-outs, case rates, flat/base rates).

· Understanding of managed care operations, provider networks, credentialing, and basic claims concepts.

· Experience using EZ-CAP or similar managed care/claims systems.

· Basic understanding of fee schedule setup, mapping, and system maintenance.

· Familiarity with RAF scoring and its relevance to reporting or configuration.

· Ability to use reporting tools such as Crystal Reports, Tableau, Excel, and basic SQL.

· Strong analytical and critical-thinking skills; ability to follow detailed workflows.

· Ability to interpret contracts and translate requirements into system setup.

· Effective collaboration with internal teams (Provider Relations, IT, Finance, Claims, etc.).

· Strong documentation skills and commitment to accuracy.

· Ability to manage confidential information appropriately.

· Adaptability in a changing environment with evolving business and regulatory needs.

· Willingness to learn new systems, tools, and technologies.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. The Provider-Reporting Analyst role requires the ability to maintain sustained focus while working extensively with computers and detailed data, often sitting or standing for extended periods. The position demands strong mental concentration to analyze information, troubleshoot issues, and uphold accuracy in a dynamic environment with evolving operational and regulatory needs. This role must be able to move through office settings as needed, participate in cross -departmental interactions, and manage confidential information responsibly while adapting to shifting priorities and workflows.

PAY RANGE

$38.00 - $43.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Associate’s degree or coursework in Healthcare Administration, Business, or related field.

Experience 

Minimum: 1+ years of healthcare administration or managed care benefits experience.

Preferred: Experience in an MSO, IPA, or health plan; familiarity with benefits interpretation systems (e.g. EZ-CAP).

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Understanding benefit structures such as co-pays, coverage limits, visit caps, and exclusions.

· General knowledge of Medi-Cal, Medicare, and commercial plan benefits.

· Ability to read and interpret benefit information from contracts and plan documents.

· Strong accuracy and attention to detail in data entry and documentation.

· Ability to identify discrepancies and perform basic benefit audits.

· Effective problem-solving and cross-functional communication skills.

· Ability to prioritize workload and meet deadlines.

· Professional communication skills, both written and verbal.

· Ability to maintain confidentiality and follow HIPAA compliance.

· Competence using spreadsheets and tracking tools for benefit updates.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. The position requires extended periods of sitting while working on a computer and using a telephone or headset, along with routine movement such as walking, standing, and bending. The role may also involve occasionally lifting items weighing up to 15-20 pounds. During peak workloads or audit periods, extended work hours may be necessary. To perform essential job functions effectively, the employee must maintain standard visual capabilities, including close and distance vision, color and peripheral vision, depth perception, and ability to adjust focus.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Coursework or certification in healthcare administration, quality improvement, or related field.

Experience 

Minimum: General office or administrative experience. Computer proficiency and experience using Microsoft Office (Word, Excel, Outlook, Access, PowerPoint).

Preferred: Experience in healthcare, managed care (HMO), utilization management, or quality improvement. Experience supporting projects or data tracking.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Typing proficiency at 40 words per minute (with accuracy)

QI-related certifications (e.g. Lean Six Sigma Yellow Belt) are preferred but not required.

Skills, Knowledge & Abilities

· Strong organizational and time-management skills.

· Ability to manage multiple tasks with accuracy and attention to detail.

· Strong written and verbal communication abilities.

· Knowledge of office equipment (fax, printer, coper, scanners, etc.).

· Ability to work independently and collaboratively.

· Flexibility, adaptability, and professionalism in a fast-paced environment.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role primarily involves computer-based work, with sitting required for most of the workday. Light physical activity is occasionally needed, including standing, walking, and lifting items up to 20 pounds. The position also requires routine mobility tasks such as bending, reaching, squatting, and climbing stairs multiple times per day. Work is performed in a typical office environment with moderate noise levels. The role requires strong focus, the ability to multitask, meet deadlines, and maintain confidentiality and attention to detail.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Coursework or training in healthcare administration, medical billing, or related field.

Experience 

Minimum: 5+ years of experience processing managed care health claims.

Preferred: 2+ years of direct Provider Dispute Resolution and/or Appeals experience within Medicare, Medi-Cal/Medicaid, Commercial, PPO, and/or HMO environments.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Strong working knowledge of managed care claims operations and regulatory requirements, including dispute and appeal timeliness standards.

· Proficiency with medical coding concepts (ICD-10, CPT, HCPCS, DRG, ASC).

· Experience with UB-04 and CMS-1500 claim forms.

· Ability to analyze complex data, identify discrepancies, and apply contract terms accurately.

· Strong written and verbal communication skills in English.

· Effective time management skills with the ability to manage competing priorities and workload volumes.

· Intermediate proficiency with Microsoft Office applications, including Word and Excel.

· Demonstrated problem-solving skills and attention to detail.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position primarily involves sedentary work with routine use of a computer and standard office equipment. The role may require occasional light physical activity (up to 10 pounds) and brief periods of bending, reaching, or filing. The employee must be able to maintain concentration for extended periods, analyze detailed information, and meet regulatory deadlines, with or without reasonable accommodation.

PAY RANGE

$33.50 - $39.50 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School diploma or equivalent. 

Preferred: Associate degree in healthcare administration or related field. Medical Assistant Certificate.

Experience 

Minimum: At least one year of experience in a healthcare environment.

Preferred: Experience working in a Managed Services Organization (MSO), Independent Physician Association (IPA), health plan, hospital or post-acute care setting, or utilization management or care coordination department. Experience with referrals, authorizations, or care coordination workflows. Experience working with Medicare Advantage or Medi-Cal populations. Experience using electronic medical records or care management systems.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Knowledge of healthcare coordination workflows preferred

· Strong organizational and time management skills

· Excellent communication and interpersonal skills

· Ability to manage multiple tasks and priorities

· Strong attention to detail and accuracy

· Ability to work independently and as part of a team

· Proficiency with Microsoft Office and electronic healthcare systems

· Ability to maintain confidentiality of protected health information

· Ability to communicate effectively with healthcare providers and staff

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Work is performed primarily in an office, remote, or healthcare coordination environment. This position requires prolonged sitting, frequent use of a computer, telephone, and electronic care management systems. The employee must be able to review clinical and administrative documentation, communicate clearly with providers and staff, and manage multiple tasks simultaneously. Occasional standing, walking, or local travel to healthcare facilities may be required. The role requires the ability to lift and carry work-related materials weighing up to 15 pounds. Visual acuity, attention to detail, and the ability to maintain focus in a fast-paced healthcare environment are essential.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent required

Preferred: Associate’s degree or higher in healthcare administration, nursing, public health, social services, or related field. Certification as a Medical Assistant or Care Coordination certification.

Experience 

Minimum: At least two years of experience in healthcare coordination, care management support, medical office operations, or related healthcare setting.

Preferred: Experience in ambulatory care, outpatient care coordination, managed care, or population health programs. Experience working with Medi-Cal, Medicare Advantage, or managed care populations in California. Experience using electronic health records and care management platforms.

Skills, Knowledge & Abilities

  • Strong organizational and time management skills.
  • Excellent interpersonal and communication skills.
  • Ability to communicate effectively with patients, providers, and interdisciplinary teams.
  • Knowledge of outpatient care coordination processes and healthcare delivery systems.
  • Ability to manage multiple priorities and meet deadlines.
  • Proficiency with electronic health records and computer applications.
  • Understanding of chronic disease management and preventive care practices.
  • Knowledge of community resources and social service programs.
  • Ability to maintain confidentiality and handle sensitive information appropriately.
  • Ability to work independently and collaboratively within a team environment.
  • Ability to identify issues and escalate appropriately to ensure patient safety and continuity of care.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Primarily sedentary work in an office or clinical setting; prolonged sitting and frequent use of computer, keyboard, and telephone. May require occasional standing, walking, or local travel to clinic locations. Ability to lift up to 20 pounds occasionally. Visual and auditory acuity required to review documentation and communicate effectively.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent and completion of a Medical Assistant program.

Experience 

Minimum: Previous experience performing Medical Assistant duties or one year of education above high school with coursework related to the nursing assistant or medical assisting field

Preferred: Experience in a Primary Care, Family Medicine, or Internal Medicine setting

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Medical Assistant certification (CMA, RMA, or equivalent)

Basic Life Support (BLS) certification

This position requires a valid California driver’s license or other government-issued photo identification. This requirement is necessary to obtain authorized access to Epic systems and related clinical applications utilized at clinic sites. Employees must be able to present acceptable identification that satisfies facility security, credentialing, and system access protocols as a condition of employment and ongoing access to assigned work locations.

Skills, Knowledge & Abilities

· Knowledge of medical assisting principles, clinical procedures, and patient care standards

· Proficiency in electronic medical record (EMR) systems and Microsoft Office applications

· Strong interpersonal, communication, and customer service skills

· Ability to multitask, prioritize duties, and work efficiently in a fast-paced environment

· Commitment to patient-centered care, confidentiality, and teamwork

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. The position primarily operates indoors in a medical clinic setting with controlled temperatures. Duties may require prolonged standing, walking, assisting patients, occasional lifting, and exposure to infectious diseases or hazardous materials.

PAY RANGE

$25.00 - $28.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Completion of a pharmacy technician training program. 

Experience 

Minimum: 0-1 years of relevant pharmacy technician experience, or equivalent combination of education and training. 

Preferred: One or more years of experience in a retail, specialty, hospital, or outpatient pharmacy setting. IV or sterile compounding experience is a plus.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Active registration as a Pharmacy Technician with the California Board of Pharmacy required.

National Pharmacy Technician Certification (PTCB or equivalent) preferred.

Skills, Knowledge & Abilities

· Working knowledge of generic and brand-name medications, pharmacy calculations, and common prescription abbreviations.

· Familiarity with medical terminology.

· Ability to follow written and verbal instructions with a high degree of accuracy.

· Strong attention to detail and organizational skills.

· Effective verbal and written communication skills.

· Ability to maintain patient confidentiality and comply with HIPAA requirements.

· Basic computer skills, including use of pharmacy management and billing systems.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical, mental, and environmental demands described below are representative of those required to perform the essential functions of the job, with or without reasonable accommodation. The employee must be able to stand, walk, and move frequently throughout the work shift and lift, carry, push, or pull materials up to 25 pounds. Sufficient manual dexterity is required to perform pharmacy preparation and data entry tasks, along with the ability to read medication labels, prescriptions, and computer screens. The role requires the ability to work effectively in a fast-paced healthcare environment with frequent interruptions while maintaining focus, accuracy, and attention to detail during repetitive tasks. 

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduated from an accredited Licensed Vocational Nursing program.

Preferred: Additional training or coursework in utilization management, care coordination, or managed care operations.

Experience 

Minimum: Six months to one year of clinical experience as an LVN

Preferred: Experience in utilization management support, case management assistance, discharge planning, MSO, IPA, or health plan environments.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current state Licensed Vocational Nurse license.

Skills, Knowledge & Abilities

· Understanding of utilization management processes and medical necessity documentation requirements appropriate to LVN scope of practice.

· Familiarity with medical terminology and basic ICD-10, CPT, and HCPCS coding concepts.

· Ability to follow clinical protocols, guidelines, and escalation pathways.

· Strong organizational, time management, and documentation skills.

· Effective verbal and written communication skills.

· Ability to prioritize tasks and respond effectively during on-call hours under supervision.

· Proficiency with electronic medical records, utilization management systems, and Microsoft Office applications.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical, mental, and environmental demands described below are representative of those required to perform the essential functions of this position, with or without reasonable accommodation. The role involves primarily sedentary work with extended periods of sitting, screen time, typing, and telephone use, along with occasional standing, walking, bending, and lifting of materials up to 20 pounds. The position requires sustained attention to accurately process clinical information and follow established protocols during on-call hours, as well as the ability to work evenings, nights, weekends, and holidays in accordance with assigned on-call schedules.

PAY RANGE

$34.00 - $37.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: Graduated from an accredited Registered Nursing program.

Preferred: Bachelor of Science in Nursing (BSN)

Experience 

Minimum: One year of clinical experience as a Registered Nurse.

Preferred: One to two years of experience in utilization management, case management, discharge planning, MSO/IPA, or health plan settings.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current state Registered Nursing license.

Skills, Knowledge & Abilities

· Knowledge of utilization management principles, medical necessity determination, and regulatory requirements relevant to managed care.

· Familiarity with Milliman Care Guidelines, CMS requirements, NCQA standards, and delegated UM workflows.

· Basic understanding of ICD-10, CPT, and HCPCS coding.

· Strong clinical judgment, critical thinking, and problem-solving skills within RN scope of practice.

· Effective verbal and written communication skills, including professional interaction with physicians and clinical leadership.

· Ability to independently prioritize and manage multiple urgent tasks during on-call hours.

· Proficiency with electronic medical records, utilization management platforms, and Microsoft Office applications.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical, mental, and environmental demands described below are representative of those required to perform the essential functions of this position, with or without reasonable accommodation. The role involves primarily sedentary work with extended periods of sitting, screen time, typing, and telephone use, along with occasional standing, walking, bending, and lifting of materials up to 20 pounds. The position requires sustained mental focus to evaluate complex clinical information and make timely, sound decisions during on-call hours, as well as the ability to work evenings, nights, weekends, and holidays in accordance with assigned on-call schedules.

PAY RANGE

$45.00 - $48.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent

Preferred: College coursework in healthcare, social services, or related field

Experience 

Minimum: 2+ years of experience in a managed care, IPA, MSO, or healthcare environment

Preferred: Experience working with California Children Services (CCS)

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Knowledge of medical terminology and coding systems including CPT, HCPCS, ICD-9/10, and RVS

· Proficiency with Microsoft Office (Word, Excel, Outlook, Teams), Zoom, and Adobe

· Strong organizational and time-management skills with the ability to multitask

· Strong written and verbal communication skills

· Ability to work independently in a fast-paced, highly confidential environment

· Strong problem-solving and critical-thinking skills

· Bilingual English/Spanish preferred

 PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role requires prolonged periods of sitting, frequent computer use, telephone communication, and the ability to manage multiple priorities while maintaining attention to detail. Work may be performed in a remote or office-based environment.

PAY RANGE

$26.00 - $29.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Bachelor’s degree in Healthcare Administration, Business Administration, Public Health, Finance, or related field.

Experience

Minimum: 5 years of progressive experience in healthcare finance, managed care analytics, or reimbursement within an MSO, Independent Physician Association (“IPA”), health plan, Accountable Care Organization (“ACO”), or large medical group. Hands-on experience with capitation, medical expense analysis, risk adjustment (RAF/HCC), and value-based payment structures. Experience working with claims, encounter data, capitation files, eligibility files, and payer reporting. Background in financial modeling, budgeting, forecasting, and variance analysis. Preferred: 7+ years of managed care experience in delegated-risk environments (Medicare Advantage, Medicaid managed care, and Commercial Health Maintenance Organization (“HMO”). Experience leading or mentoring analysts or finance teams. Advanced expertise in financial modeling, capitation structures, and medical cost performance management. Demonstrated success leading cross-functional teams in MSO or risk-bearing settings. Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration for this position. Certification(s) None

Skills, Knowledge & Abilities

• Deep understanding of managed care financial models, including capitation, PMPM revenue, shared savings, risk sharing, IBNR, risk adjustment, medical utilization and medical loss ratio (MLR) dynamics.
• Working knowledge of healthcare claims and encounter data, eligibility files, risk score methodologies (RAF/HCC), and reimbursement structures across Medicare Advantage, Commercial HMO, and Medicaid managed care.
• Familiarity with delegated-risk requirements, health plan reporting standards, and compliance expectations set by the Centers for Medicare & Medicaid Services (“CMS”, Department of Managed Health Care (“DMHC”), and other regulatory bodies.
• Broad understanding of operational functions influencing managed care performance (e.g., utilization management, contracting, provider relations, revenue cycle, and claims operations).
• Ability to analyze large datasets, identify cost drivers, and translate complex financial trends into clear, actionable insights.
• Proficiency in financial planning tools and processes, including budgeting, forecasting, modeling, and variance analysis for capitation and medical expenses.
• Strong Excel skills and experience with analytics/reporting tools such as Power BI, Tableau, and SQL.
• Excellent leadership and people management skills, with the ability to motivate and develop staff in a high-accuracy, high-accountability environment.
• Exceptional communication skills, both written and verbal, with the ability to interact effectively with internal teams, external partners, and leadership, with a high regard for attention to detail.
• Ability to manage multiple priorities, meet deadlines, and work in a fast-paced, compliance-driven environment.
• Ability to maintain confidentiality and adhere to HIPAA regulations.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in a standard office or hybrid office environment and requires prolonged periods of sitting, frequent use of a computer, telephone, and video conferencing platforms, and sustained visual focus when reviewing eligibility records, enrollment data, reports, policies, and contracts. The role requires significant mental concentration, analytical thinking, and attention to detail when interpreting benefits, eligibility rules, capitation-related data, and regulatory requirements. The position may require occasional local travel to health plans, administrative offices, or organizational sites for meetings, audits, or collaborative work sessions, with occasional regional travel as needed. The employee must be able to lift, carry, push, or pull items up to approximately 20 pounds (e.g., laptop, files, binders, or work materials). This role requires adequate visual and auditory acuity to review written and electronic materials, analyze data and reports, and communicate effectively with staff, leadership, health plan representatives, and other internal and external stakeholders. The role may involve periods of high workload, time-sensitive deadlines, and exposure to confidential or complex information requiring discretion, professionalism, and sound judgment.

SALARY RANGE

$115,000 - $135,000 / annually

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School Diploma or equivalent.

Preferred: Additional coursework or training in healthcare administration, medical billing, or managed care.

Experience 

Minimum: Five years of managed care claims processing experience.

Preferred: Two – three years of recent institutional/hospital claims experience involving Medicare, Medi-Cal, HMO, PPO, and Commercial products.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Professional claims or medical billing certifications preferred.

Skills, Knowledge & Abilities

· Advanced knowledge of institutional claims processing, including UB-04 and CMS-1500 claim forms.

· Strong understanding of DRG, OPPS/APC, Ambulatory Surgery, and RBRVS reimbursement methodologies.

· Working knowledge of Medi-Cal, Medicare, and California managed care regulations, including prompt payment requirements.

· Proficiency with claims processing systems, third-party pricing software, and standard office applications (Microsoft Office).

· Strong analytical, problem-solving, and decision-making abilities.

· Excellent written and verbal communication skills; ability to read, write, and communicate effectively in English.

· Ability to manage multiple priorities in a fast-paced, deadline-driven environment.

· Demonstrated attention to detail and commitment to accuracy and compliance.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role is primarily sedentary and requires the ability to sit for extended periods while performing work at a computer workstation. The position involves light physical activity, including the ability to lift up to 10 pounds and to bend, stoop, reach, and file materials as needed. The employee must be able to frequently use a computer, keyboard, and standard office equipment, and maintain focus, manage workload pressures, and meet deadlines in a professional healthcare office or remote work environment.

PAY RANGE

$31.00 - $36.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Bachelor’s degree in Information Technology, Computer Science, Information Systems, Business Systems, Engineering, or related discipline.

Preferred: Master’s degree in Information Systems, Technology Management, Business Administration, or a related field.

Experience 

Minimum: 10+ years of professional experience working with EDI systems, integrations, or electronic transaction workflows. 5+ years in a leadership or management role overseeing technical, operational, or integration teams. Extensive experience with X12, HIPAA transactions, data mapping, secure file transmission, and EDI translator tools.

Preferred: Experience in healthcare, insurance, supply chain, or industries with heavy EDI utilization. Experience with large-scale enterprise integration environments (e.g. API-based systems, middleware, ETL tools). Proven experience leading multi-department transformation initiatives.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s) 

Preferred: Certifications related to EDI, integration technologies, project management, or enterprise systems (e.g. CompTIA, Microsoft, PMI-PMP, HL7/FHIR, or platform-specific credentials).

 Skills, Knowledge & Abilities 

• Advanced knowledge of EDI standards, transaction sets, data structures, and integration architecture.

• Expertise with mapping tools, translators, communication protocols (SFTP/FTP/AS2), and middleware platforms.

• Exceptional analytical and troubleshooting ability, especially with large-scale or high-complexity issues.

• Strong leadership, communication, and relationship-building abilities across technical and non-technical teams.

• Ability to manage multiple enterprise initiatives, competing priorities, and high-stakes deadlines.

• High attention to detail, data accuracy, and process integrity.

• Ability to design and implement policy frameworks, SOPs, governance structures, and performance standards.

• Demonstrated ability to drive organizational adoption of technology and process improvements.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. The role is primarily computer-based and requires sustained concentration for detailed technical work. It demands strong mental agility for complex problem-solving and strategic oversight. The position may involve occasional movement within office settings and periodic travel to other organizational or partner locations. Work is performed in a fast-paced environment with shifting priorities and multiple deadlines. The role requires sound judgment, and consistent accuracy when handling sensitive or high-impact information.

PAY RANGE

$160,000 - $180,000 / annually

Requirements

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: High school diploma or GED equivalent required

Preferred: Associate’s degree or higher in healthcare administration, public health, social services, or related field. 

Experience 

Minimum: At least one year of experience in one or more of the following areas: risk adjustment, coding compliance, medical record review, managed care, healthcare administration, managed care or MSO environment, medical office or provider operations.

Preferred: Experience supporting Medicare Advantage Risk Adjustment programs. Experience supporting CMS RADV audits or coding compliance audits. Experience in an MSO, IPA, health plan, delegated entity, or managed care environment. Experience working with electronic health records, coding software, or Risk Adjustment platforms.

Certification(s)

Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or other coding certification preferred.

Skills, Knowledge & Abilities

• Knowledge of CMS Risk Adjustment methodology, HCC documentation requirements, and RAF score principles. 
• Understanding of Medicare Advantage Risk Adjustment, coding compliance, and documentation integrity requirements. 
• Familiarity with CMS RADV audit standards, DMHC regulatory requirements, NCQA standards, and delegated health plan oversight requirements. 
• Ability to identify documentation deficiencies, coding inconsistencies, compliance risks, and audit-related concerns. 
• Strong organizational, analytical, auditing, and data tracking skills with exceptional attention to detail and accuracy. 
• Ability to maintain accurate records, audit logs, compliance documentation, and reporting tools. 
• Proficiency with electronic health records, Risk Adjustment platforms, coding software, and Microsoft Office applications. 
• Strong verbal and written communication skills with the ability to communicate professionally with providers, coders, leadership, health plans, and interdisciplinary teams. 
• Ability to handle confidential and sensitive information in compliance with HIPAA and organizational policies. 
• Ability to manage multiple priorities, deadlines, and audit-related activities in a fast-paced managed care environment.
• Ability to work independently while collaborating effectively within interdisciplinary operational and compliance teams.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Primarily sedentary work involving prolonged computer use. Occasional standing, walking, and local travel may be required. Ability to lift up to 20 pounds occasionally. Requires strong attention to detail, data analysis capability, and effective communication skills. Work is performed in an office or remote environment supporting electronic medical record and Risk Adjustment systems.

PAY RANGE

$30.00 - $34.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: High school diploma or GED equivalent required. Graduate of an accredited Licensed Vocational Nursing (LVN) program.

Preferred: Additional coursework or certifications in case management, utilization management, care coordination, or managed care preferred.

Experience 

Minimum: At least Two (2) years of clinical experience in one or more of the following settings: post-acute care, skilled nursing, acute care hospital, rehabilitation, home health, hospice, utilization management, care coordination, or case management.

Preferred: Prior experience in an MSO, IPA, health plan, or Medi-Cal managed care setting.

Any combination of education and experience that provides the required knowledge, skills, and abilities may be considered.

Certification(s)

Active and unrestricted California Licensed Vocational Nurse license.

Skills, Knowledge & Abilities

· Working knowledge of utilization management, managed care principles, case management, discharge planning, and transition-of-care processes across the post-acute continuum. 

· Knowledge of post-acute care settings and services, including skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), inpatient rehabilitation facilities (IRFs/ARUs), home health, hospice, assisted living, and community-based care resources. 

· Familiarity with CMS, Medi-Cal, DMHC, NCQA, Medicare Advantage, and California managed care regulatory requirements, including authorization and medical necessity review processes. 

· Ability to apply approved clinical criteria, policies, guidelines, and established protocols within LVN scope of practice, including InterQual®, Milliman®, health plan guidelines, and internal utilization management standards. 

· Understanding of care coordination, readmission prevention strategies, continuity of care practices, and appropriate level-of-care determinations. 

· Ability to identify and escalate clinical, quality, psychosocial, discharge planning, and utilization concerns to appropriate clinical leadership. 

· Strong organizational, analytical, documentation, and time-management skills with the ability to prioritize and manage multiple cases and competing deadlines in a fast-paced healthcare environment. 

· Ability to coordinate care effectively across multiple provider groups, facilities, interdisciplinary teams, health plans, and community resources. 

· Clear and professional verbal and written communication skills with the ability to communicate effectively with providers, members, caregivers, facilities, leadership, and external partners. 

· Proficiency with electronic medical records (EMR), utilization management and case management platforms, authorization systems, and Microsoft Office applications. 

· Ability to maintain confidentiality and exercise sound judgment in handling protected health information and sensitive matters in compliance with HIPAA and organizational policies. 

· Ability to work independently while also functioning collaboratively within an interdisciplinary managed care and post-acute care environment. 

· Demonstrated adaptability, professionalism, and problem-solving skills in supporting operational, regulatory, and patient care coordination needs.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

 The demands described below are representative of those required to perform the essential functions of this position, with or without reasonable accommodation. The role is primarily sedentary, with sitting required approximately 70% of the time. The employee may occasionally be required to stand, walk, bend, or lift items weighing up to 20 pounds. The position requires frequent use of computers, telephones, and written or electronic communication. Local travel to hospitals, skilled nursing facilities, or MSO offices may be required. The employee must be able to work effectively in office and healthcare facility environments.

PAY RANGE

$35.00 - $38.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education

Minimum: High school diploma or equivalent.
Preferred: Associate’s degree or college coursework in Healthcare Administration, Business, or related field.

Experience 

Minimum: at least one year of customer service, call center, or healthcare administrative experience.
Preferred: Experience in managed care, MSO, IPA, or health plan environment; familiarity with member/provider systems (e.g., EZ-Cap, Salesforce, or comparable CRM).

Skills, Knowledge & Abilities

· Strong customer service and interpersonal skills with a commitment to service excellence.

· Excellent verbal and written communication skills; ability to explain benefit and process information clearly.

· Ability to de-escalate concerns and resolve issues using empathy, professionalism, and sound judgment.

· Strong attention to detail and accuracy in documentation and data entry.

· Ability to navigate multiple systems and applications while on calls; strong computer proficiency.

· Working knowledge of call center practices and performance metrics (AHT, ASA, FCR, service level).

· Familiarity with managed care concepts including eligibility, benefits, authorizations, claims routing, and provider network structure.

· Ability to follow scripts, policies, and workflows and to adapt to benefit or system changes.

· Ability to recognize urgent or complex issues and escalate appropriately per protocol.

· Commitment to confidentiality and compliance with HIPAA and organizational privacy and security policies.

· Strong organizational and time management skills; ability to manage competing priorities and deadlines.

· Ability to work effectively in a team environment and collaborate across departments.

· Customer-focused mindset with the ability to maintain composure in a fast-paced environment.

· Ability to maintain professionalism and confidentiality at all times.

· Experience with customer service platforms (EZ-Cap, Salesforce, CRM systems) preferred.

· Bilingual in English/Spanish skills preferred.

· Ability to learn and apply regulatory and health plan requirements relevant to customer service operations.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. There will be prolonged periods of sitting, working on a computer, and using a telephone/headset. While performing the duties of this job, the employee will regularly be required to walk, stand, bend, lift and/or move up to 15-20 pounds. Ability to work extended hours during peak periods or audit timelines, as needed. Requires visual acuity to review documents, reports, and system data. Specific vision abilities required by this job include close, distance, color, peripheral vision, depth perception and the ability to adjust focus. 

PAY RANGE 

$28.00 - $32.00 / hourly

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education

Minimum: High school diploma or equivalent, or equivalent combination of education and experience.

Experience

Minimum: Two years of healthcare claims processing or claims adjudication experience, including experience interpreting benefits and reimbursement rules. Experience working with claim denials, adjustments, and provider inquiries. Working knowledge of medical billing/coding basics (CPT, HCPCS, ICD-10, revenue codes) and how coding impacts adjudication. Experience using claims systems and/or EDI workflows preferred.

Skills, Knowledge & Abilities

· Knowledge of end-to-end claims lifecycle including intake, edits, adjudication, pricing, payment, denials, adjustments, and recoveries.

· Ability to interpret provider contracts, fee schedules, and reimbursement methodologies (FFS, DRG/APC, capitation, bundled payments).

· Strong analytical and problem-solving skills; able to research discrepancies and determine appropriate resolution.

· Attention to detail and accuracy with ability to meet production, turnaround time, and quality standards.

· Effective written and verbal communication; professional customer service with providers and internal stakeholders.

· Working knowledge of HIPAA transactions (837/835) and claims-related regulatory requirements including prompt pay and dispute resolution.

Proficient with claims systems, Microsoft Office/Google Workspace, and basic reporting tools. 

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves   prolonged periods of sitting, computer use, and data review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Occasional lifting of materials up to approximately 10–20 pounds may be required. The position may require extended work hours or weekend work to meet operational and regulatory deadlines.

PAY RANGE

$28.85 - $33.65 / hourly