Medical Director, Utilization Management L.A. Care Health PlanMedical Director, Utilization ManagementLos Angeles, CAThis position plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA) and requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action to minimize utilization variation, prevent improper payments and ensure financial stewardship. Job Summary The Medical Director, Utilization Management provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions.
NewClinical Documentation Integrity Specialist II - Hybrid FT Days Torrance Memorial Medical CenterClinical Documentation Integrity Specialist II - Hybrid FT DaysTorrance, CaliforniaUses clinical/nursing/coding knowledge to concurrently review and assess the medical record within 24-48 hours of admission including but not limited to physician documentation, lab and radiology results, nursing, nutrition, physical therapy and other provider’s documentation to determine that the most accurate severity of illness and expected risk of morality is reflected in the patient’s health record. Obtains additional documentation from physician or other qualified healthcare provider for clarification when there is conflicting, incomplete or ambiguous information in the healthcare record regarding any reportable data elements dependent on health record documentation.
Senior Director, Strategic Analytics Tendo Systems IncSenior Director, Strategic AnalyticsCARemote$2,024–$2,025This person will combine deep clinical informatics expertise with hands-on Databricks engineering and AI/ML skill to build algorithms that do two things simultaneously: (1) close documentation and coding gaps that affect risk adjustment, mortality index, and quality attribution, and (2) identify gaps and variation in the actual clinical processes of care that drive the metrics used by national hospital ranking and rating programs (e.g., CMS Star Ratings, U.S. News & World Report, Leapfrog, Vizient, Healthgrades, IBM Watson Health/Chartis 100 Top Hospitals). Maintain expert-level, current knowledge of major hospital ranking, rating, and benchmarking methodologies, including but not limited to: CMS Hospital Compare/Star Ratings, CMS Value-Based Purchasing and Hospital-Acquired Condition programs, U.S. News & World Report Best Hospitals methodology, Leapfrog Hospital Safety Grade, Vizient quality and safety benchmarking, Healthgrades, and payer-specific quality programs.
Medical Director, Clinical Policy L.A. Care Health PlanMedical Director, Clinical PolicyLos Angeles, CAThis position ensures clinical policies and utilization management frameworks are evidence-based, operationally sound, compliant with regulatory and accreditation requirements, and aligned with organizational goals related to quality, safety, affordability, and member experience. The Medical Director oversees policy architecture, authorization strategy, and utilization oversight across all lines of business, ensuring clinical intent is accurately translated into authorization requirements, coding structures, and system configuration through partnership with internal teams.
Supervisor, Benefit Distribution And Installation (50544) Western Growers AssociationSupervisor, Benefit Distribution And Installation (50544)Irvine, CAInterface with personnel in all field offices, TPA employers and brokers, and management staff as necessary to communicate any problems or issues with paperwork submission or installation issues for new business, plan changes, rate renewals and rate changes. Oversee the implementation of each new client with the third party administratorion (TPA) client, with necessary communication between the broker, PCMI operational areas, the client and any external vendor as necessary, including the review, completion & sign-off on Client Set-up Sheetsforms/screens.
Business Development Executive (MedInsight) Milliman IncBusiness Development Executive (MedInsight)Pasadena, CARemote$120,635–$199,065 / yearMedInsight is a subsidiary of Milliman; a global, employee-owned consultancy providing actuarial consulting, retirement funding and healthcare financing, enterprise risk management and regulatory compliance, data analytics and business transformation as well as a range of other consulting and technology solutions. Primary Responsibilities: Develop deep expertise in MedInsight's risk adjustment software and analytics, and in the surrounding market (CMS-HCC models, RADV, quality programs, value-based care, and the competitive landscape) to engage prospects as a credible advisor.
10806 - Sr. Software Engineer (Java/J2EE/Cloud) Hyundai Autoever America10806 - Sr. Software Engineer (Java/J2EE/Cloud)Costa Mesa, CA$103,170–$158,873 / yearWork closely with multiple stakeholders to translate Connected Car feature specifications/requirements into high quality, timely deliverables as a strong hands-on technical member in Connected Car project development activities. Provide technical direction and guidance to the engineering team/vendor to create designs, develop systems, resolve issues, and manage Connected Car development schedule.
Sr. Physician Coder - Interventional Radiology - Remote 26-00157 Alura Workforce SolutionsSr. Physician Coder - Interventional Radiology - Remote 26-00157Fountain Valley, CARemoteDESCRIPTION Under the direction of the Coding Compliance Manager, the Senior Specialty Physician Coder is responsible for reviewing and accurately coding physician services to ensure compliant reimbursement and complete charge capture. This role is highly specialized in Interventional Radiology (IR) and requires a coder who can independently perform complex IR coding from day one.
Field Reimbursement Manager - Kidney (Central California - Los Angeles & San Bernardino) Vertex Pharmaceuticals IncField Reimbursement Manager - Kidney (Central California - Los Angeles & San Bernardino)Los Angeles, CA$136,000–$204,000 / yearKey Duties and Responsibilities: Compliantly establish strong connections with key nephrology office personnel, including members of the care team and administrative staff responsible for prior authorizations and patient access to specialty medications, to support patient access to prescribed medications. At Vertex, our Total Rewards offerings also include inclusive market-leading benefits to meet our employees wherever they are in their career, financial, family and wellbeing journey while providing flexibility and resources to support their growth and aspirations.
Case Manager West Coast Alnylam Pharmaceuticals IncCase Manager West CoastCARemote$85,500–$115,600 / yearThanks to the commitment of every employee globally, Alnylam is proud to have been recognized as one of Fast Company's 2021 Best Workplaces for Innovators, a Science Magazine Top Employer three years in a row (2019-2021), a Boston Globe Top Places to Work seven years in a row (2015-2021), a Great Place to Work in Asia, Japan, Brazil, the U.K., Germany, Spain, Netherlands, Italy, France and Switzerland, Seramount's 100 Best Companies (formerly Working Mother 100 Best Companies) and Best Companies for Dads, Bloomberg's Gender Equality Index two years in a row (2021-2022), among others. Fosters collaborative relationships with all internal and external customers including but not limited to Patient Education Liaisons, medical, sales, field reimbursement, corporate accounts, patient advocacy, insurance company case managers, specialty pharmacies, home health agencies, and office coordinators.
Compliance Specialist - Medical Billing Advantage Healthcare ServicesCompliance Specialist - Medical BillingHuntington Beach, CAThis role serves as a key operational partner to Compliance, Pharmacy Operations, Revenue Cycle, and Credentialing teams to support licensing activities, billing compliance, audit readiness, reimbursement requirements, and ongoing regulatory compliance. The ideal candidate combines strong administrative discipline with knowledge of pharmacy operations, licensing regulations, healthcare reimbursement, medical billing, pharmacy claims processing, and regulatory documentation.
Clinical Documentation Integrity Specialist UCLA Health SystemClinical Documentation Integrity SpecialistLos Angeles, CARemote$100,161.36–$218,718 / yearThis role involves daily review of high-acuity patient records to identify potential and active payer denials, assess clinical validity, and to support denial prevention, analysis, and appeals across inpatient and outpatient settings; continuously communicating with department staff; educating physicians, residents, and mid-levels; and assisting with appropriate documentation strategies. You will prepare and submit high quality appeal letters supported by clinical evidence, regulatory guidelines, and payor-specific medical necessity criteria, while identifying denial trends and root causes and provide feedback to the CDI and Clinical teams.
Senior Clinical Documentation Integrity Specialist Blue Cross and Blue Shield AssociationSenior Clinical Documentation Integrity SpecialistLos Angeles, CAPursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner. The Senior Clinical Documentation Integrity Specialist ensures accurate, complete, and compliant clinical documentation that appropriately reflects severity of illness, risk of mortality, and supports correct reimbursement.
Claims Manager, Medicare Advantage Plan University of CaliforniaClaims Manager, Medicare Advantage PlanLos Angeles, CA$95,400–$208,300 / yearThe Claims Manager of the Medicare Advantage Plan will: Implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments. As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.
Senior Actuary Health Plan Analytics ReveleerSenior Actuary Health Plan AnalyticsCARemote$150,000–$185,000 / yearThis role builds member-level actuarial models that quantify risk adjustment performance, HCC (Hierarchical Condition Category) capture, medical economics, utilization, and population health trends, and translates those models into customer-facing dashboards that inform pricing, forecasting, and program strategy. Reveleer is hiring a senior actuary to lead health plan and risk adjustment analytics for each line of business for Reveleer customers across Medicare Advantage (MA), Medicare Advantage Prescription Drug (MAPD), Affordable Care Act (ACA), Medicaid, and provider value-based contracts.
Trauma Registrar Children's Hospital Los AngelesTrauma RegistrarLos Angeles, CaliforniaRemote$55,702.40–$74,256 / yearFull timePurpose Statement/Position Summary: The trauma team provides a complete continuum of pediatric trauma care, combined with an active program of education, research and prevention, in addition to maintaining CHLA’s verification as a Level 1 Peds Trauma Center. Children’s Hospital Los Angeles is consistently ranked among the top 10 children's hospitals in the nation, delivering world-class care through more than 350 specialized programs and services.
Medical Biller United Surgical Partners InternationalMedical BillerTorrance, CARequirements KNOWLEDGE, SKILLS, QUALIFICATION and EDUCATIONAL AND /OR EXPERIENCE REQUIREMENTS: High school diploma or equivalent. United Surgical Partners International is a publicly traded company that specializes in the development and operation of Ambulatory Surgical Facilities in the U.S. and the UK.
Inpatient Audit Specialist- PRN Datavant LLCInpatient Audit Specialist- PRNCARemote$35–$45 / hourWhat You Will Do: Performs Inpatient Facility coding audits according to scope of work, for the purpose of Onboarding, Focused, Service Level Agreements or Other Types of reviews, using appropriate assignment of codes and other coding-related elements using MS DRG or APR DRGs. What We're Looking For: As an Inpatient Auditing Specialist, you will be instrumental in addressing consulting and educational needs related to coding quality, compliance assessments, external payer reviews, coding education, and coding workflow operations reviews.
NewSr. Manager, Engineering Cohere Health Technologies LLCSr. Manager, EngineeringCARemote$185,000–$225,000 / yearOpportunity Overview: We are seeking a Senior Engineering Manager to lead our Review Engineering team - roughly 20+ engineers across three squads in the US and India - building the workflows and capabilities that let clinical operations staff deliver care at scale, efficiently and with high quality. Leading through dedicated technical leads on each squad, you''ll own the reliability and technical direction of Review''s systems while partnering closely with Product, Design, Security, Clinical Operations, and peer engineering teams on shared platforms.
Associate Director, Medical Review Lead, MSRM - Remote Agios PharmaceuticalsAssociate Director, Medical Review Lead, MSRM - RemoteLos Angeles, CARemote$185,369–$308,948 / yearThe current base salary range for this position is expected to be between $185,369 and $308,948 annualized; final salary will be determined based on various factors including, but not limited to, years of relevant experience, job knowledge, skills and proficiency, degree/education, and internal comparators. This role provides oversight of medical review for Individual Case Safety Reports (ICSRs) across investigational and marketed products, ensuring medical accuracy, regulatory compliance, and high-quality safety data to support pharmacovigilance and risk management activities.