Blue Shield to Appeal State Decision to Revoke Not-For-Profit Status

March 30, 2015 | VOLUME 22 | NUMBER 13

TOP STORIES

To Our Advertisers: Blue Shield to Appeal State Decision Our offices will be closed on Friday, April 3. to Revoke Not-for-Profit Status To accommodate the short week, for the April 6 issue of California Healthfax, all ads will be Insurer says appeals process could take two years due on Wednesday, April 1. Thank you. Blue Shield of California plans to appeal a state decision to rescind its tax- exempt status in California as a not-for-profit insurer. The ruling by the California Franchise Tax Board (FTB) could require Blue Shield to pay millions of dollars in retroactive state taxes. Blue Shield vice presi- Published every Monday, California Healthfax is dent of corporate communications Steve Shivinsky said the insurer plans to copyrighted by HealthLeaders Media, a division of BLR, 75 Sylvan St., Suite A-101, Danvers, appeal the decision. MA 01923, and is transmitted solely to the sub- “We have filed a protest against the FTB ruling and this will take up to two scriber. Any unauthorized copying, duplication or years to decide,” said Shivinsky. “Blue Shield as a company and a management transmission is strictly prohibited. Annual sub- team firm believes it is fulfilling its not-for-profit mission and commitment to the scriptions are $179. For group and bulk subscrip- community. We are, and will remain, a not-for-profit company…” tions, call 800-650-6787. Shivinsky noted that the decision only pertains to Blue Shield’s status in the CUSTOMER SERVICE CENTER state. “Blue Shield has paid federal taxes since 1986,” said Shivinsky. “Blue Shield E-mail Subscribers: If you do of California’s effective tax rate on pre-tax profits exceeds 45% annually …” Blue not receive your copy of HealthFax, Shield of California and other Blue Cross and Blue Shield plans in the U.S. lost their send a request to: [email protected]. federal tax-exempt status under reforms to the federal tax code approved in 1986. For renewals or other subscription questions, Officials for the Franchise Tax Board declined to comment on the ruling or please call: 800-650-6787. By fax: 866-592-7573. what prompted the state audit that led to its decision issued in August 2014. The By e-mail: [email protected]. FTB added Blue Shield to a list of companies that had their tax-exempt status EDITORIAL SUBMISSIONS revoked and posted the information on its website but did not comment on it at To submit an item for consideration, con- the time. The decision will also require Blue Shield to file tax returns dating back tact Doug Desjardins, Editor. By e-mail: to 2013. [email protected]. By phone: 760-696-3931. While not unprecedented, analysts say the action taken against Blue Shield For other questions, contact Bob Wertz, Managing is unusual. “I am not aware of any nonprofit health insurer that has been stripped Editor. By phone: 800-639-7477, ext. 3456. By e-mail: [email protected] of its tax-exempt status prior to Blue Shield,” said Gerald Kominski, a professor of health policy at the UCLA Fielding School of Public Health and director of the UCLA Center for Health Policy Research. ADVERTISING OPPORTUNITIES To advertise in California Kominski said Blue Shield has the option of converting to a for-profit insurer Healthfax, please contact Susan by but that it’s more likely to negotiate a settlement with state officials if its appeal of e-mail: [email protected]. the Franchise Tax Board decision fails. “I imagine that Blue Shield will try to reach By phone: 978-624-4594.

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IN BRIEF TOP STORIES CONTINUED FROM PAGE 1 Blue Shield cont. »»The West Contra Costa Healthcare District board of directors voted to some negotiated settlement that lays out terms and conditions necessary to regain begin shutting down Doctors Medical its tax-exempt status,” said Kominski. Center on April 21 unless it finds an State insurance commissioner Dave Jones said the ruling reflects comments eleventh-hour solution to keep the hos- he has made about Blue Shield in the past. “The Franchise Tax Board decision to pital open. According to a report in the terminate Blue Shield’s tax-exempt status confirms what I have said for years: that San Francisco Chronicle, the board said Blue Shield charges excessive rates and acts like a for-profit health insurer,” said the cash-strapped hospital in San Pablo Jones, who also accused Blue Shield of “taking advantage of a legal loophole” in has run out of options. “If in fact the order to “dodge my department’s strong consumer protection regulation and our money comes forward and we actually collection of premium taxes.” have a real opportunity to save the hos- Andy Selesnick, a partner with law firm Michelman & Robinson LLP who pital, we can call an emergency meeting has litigated against insurers on behalf of hospitals in the state, said he wasn’t and reverse this decision,” said board surprised by the decision. “They [Blue Shield] are indistinguishable from other for- chair Eric Zell. The board estimates profit insurers in the way they act toward both consumers and providers,” said that shutting down the hospital will Selesnick. “Their reimbursements are poor on the provider side and the premiums cost approximately $5.3 million and they charge consumers are on par with other insurers.” that it will use revenue from the recent The Blue Shield ruling could prompt other not-for-profit groups in the sale of hospital property to the city of healthcare industry to take steps to ensure they are abiding by state regula- San Pablo. tions. “The ruling sends a very, very strong message to large nonprofits to be sure that you’re functioning as a nonprofit, that you’re not shielding assets or »»San Francisco General Hospital revenue from taxation, and that you’re generally serving the public good,” said & Trauma Center is hiring more Kominski. —DOUG DESJARDINS than 100 registered nurses to staff a hospital tower that is due to open in December. According to a report in the UC San Francisco and John Muir San Francisco Business Times, the 283- bed facility will include an emergency to Create Coordinated Care Plan department that is double the size of ‘Bay Area Network’ scheduled to launch in 2016 the existing facility. The new tower will also increase the hospital’s capacity for UC San Francisco (UCSF) Medical Center and John Muir Health have finalized specialty care and boost the number of an agreement to form a coordinated care network that’s expected to include other inpatient beds to 686. Rachael Kagan, providers in the Bay Area. spokesperson for San Francisco General The two health systems plan to form the Bay Area Accountable Care Hospital, said most of the nursing posi- Network, a regional program that would contract directly with health plans tions will be needed for specialty areas to provide care at more competitive prices. John Muir and UCSF plan to file an such as emergency care and medical- application with the state Department of Managed Health Care for a limited surgical critical care. “We hope the new Knox-Keene license that would allow them to contract with health plans and building design, technology, and relat- share savings. ed training will make it an attractive UCSF Medical Center CEO Mark Laret said the goal is to form a “Bay Area option,” she said. network of providers” to provide coordinated care for patients. “We intend to offer this network to health plans who serve patients throughout the Bay Area,” said « CONTINUED ON PAGE 3 » « CONTINUED ON PAGE 3 » HIRE POWER: HEALTHFAX CLASSIFIED ADS WORK! PAGE 3 of 13 CALL 978-624-4594 For subscription services, call 800-753-0131 March 30, 2015

TOP STORIES CONTINUED FROM PAGE 2 IN BRIEFContinued from page 2 UC San Francisco cont. »»Dignity Health Dominican Hospital has opened a new $2.1 million endosco- Laret. “We look forward to working not just with each other, but with other health py ultrasound suite that provides a less organizations throughout the Greater Bay Area in order to provide an exceptional invasive option to diagnosing problems healthcare experience for patients.” of the liver, pancreas, and digestive tract. Hospital officials expect to attract John Muir spokesman Ben Drew said the two systems plan to launch the net- about 250 patients per year for the work next year. “The Bay Area Network is scheduled to launch in 2016 with addi- service that uses endoscopic ultrasound tional hospitals, health systems, and physician groups,” said Drew. The two health to provide high definition images of systems also plan to integrate their separate electronic health record systems to the digestive tract and internal organs. facilitate the exchange of patient data between hospitals and outpatient centers. Dignity Health financed the new suite in Both John Muir and UCSF use systems developed by Epic and “have already start- part with $1.2 million in private dona- ed to integrate” their respective systems. tions raised by the Dominican Hospital Foundation. Neither health system plans on operating its own health plan at this point, which is the reason John Muir and UCSF are applying for a limited license. “We are »»The Daughters of Charity Health applying for a limited Knox-Keene license so that we can take on full-risk capitation System (DCHS) is attracting the atten- from other health plans,” said Drew. “We will partner with existing health plans to tion of several potential buyers fol- develop a product that gives patients access to our network and we will be coordi- lowing its failed acquisition by Prime Healthcare. According to a report nating care within that network.” Drew said the two health systems are in prelimi- from Bay Area News, potential suitors nary talks with three insurers interested in participating in the network. include Alecto Healthcare Services, a John Muir operates two hospitals in the cities of Walnut Creek and Concord company owned by the brother-in-law about 30 miles east of San Francisco. UCSF Medical Center operates campuses of Prime Healthcare CEO Prem Reddy. at Mount Zion and Parnassus Heights in San Francisco and its hospitals have a Santa Clara County officials are combined total of 600 inpatient beds. reported to be interested in purchasing two DCHS hospitals in the county and The partnership with John Muir is the second UCSF has entered to expand private equity firm Blue Wolf Capital its reach beyond San Francisco. In early 2014, it finalized an affiliation agreement has expressed an interest in the entire with Children’s Hospital & Research Center Oakland. The deal allows Children’s chain. In early March, Prime Healthcare Hospital Oakland to remain autonomous but gives the hospital access to special- opted not to purchase DCHS because of ists and other resources available through UCSF Medical Center and UCSF Benioff conditions attached to the sale by state Attorney General Kamala Harris that Children’s Hospital. included keeping five of the six hospitals John Muir announced plans in January to form an accountable care organiza- open for at least 10 years. tion with insurer Health Net. The ACO will focus on care management and well- ness and prevention programs. “This partnership is well-aligned with our efforts to Population health specialist »» lower costs, enhance quality and service, and increase access to John Muir Health,” Alignment Healthcare and healthcare-technology firm Vivify Health said Lee Huskins, president and chief administrative officer of the John Muir have partnered to create a program Physician Network. —DOUG DESJARDINS

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TOP STORIES CONTINUED FROM PAGE 3 IN BRIEFContinued from page 3 that allows patients with chronic conditions to monitor their health at home Dignity Health Files Application and transmit data to their physician. Patients with chronic health condi- with State for Limited HMO tions are given kits that contain a tab- Other health systems pursuing similar plans let computer and a Bluetooth-enabled Dignity Health has applied for a state license that would allow it to contract device that measures vital signs such directly with Medicare health plans in Kern County and share in any cost savings. as blood pressure, blood oxygen, and Dignity filed an application for a limited Knox-Keene license with the state weight. The device also helps patients Department of Managed Health Care (DMHC) to launch the venture that would monitor their health and diet through involve Medicare patients who reside in Kern County, a rural region located in triggered alerts. “It’s important we Central California. Dignity did not comment on its plan other than to say that “at proactively monitor our patients and this time, we do not have plans to expand our use of the limited Knox-Keene license engage with them to ensure their beyond Kern County.” health is being properly managed at A limited license does not allow a health system to market products directly home,” said Ken Kim, MD, chief medi- to individuals and businesses or enroll members but does allow it to share cost sav- cal officer for Orange-based Alignment ings or losses with the health plans it contracts with. Dignity currently operates Healthcare. “If their clinical condition three hospitals in Kern County including Bakersfield Memorial Hospital, Mercy exacerbates, we see the alerts and can Hospital Southwest, and Mercy Hospital Downtown. take the appropriate measures to inter- Other health systems are pursuing similar plans in Northern and Central vene as necessary.” California. As part of a new joint venture, John Muir Health and UC San Francisco Medical Center applied for a restricted Knox-Keene license that would »»San Francisco General Hospital allow them to contract directly with health plans in the Bay Area for a coordinated has launched a pilot program to test care program called the Bay Area Accountable Care Network. a new diagnostic tool that screens Adventist Health is planning to launch an HMO for Medicare patients in three patients for tuberculosis (TB). counties. The plan will launch in rural Northern California in Kings, Mendocino, and According to a report in the San Tuolumne counties where there are few competitors in the Medicare HMO market. Francisco Examiner, the program The DMHC approved Adventists’ request for a full Knox-Keene license with a planned launched in March will evaluate a test launched for 2015 that has since been pushed to 2016. that monitors a patient’s specimen for Adventist is pursuing a plan more along the lines of Sutter Health, which the DNA sequence of the bacteria that launched its Sutter Health Plus HMO in January 2014 in Sacramento County and causes TB. The test can produce results seven other counties and will expand to Sonoma County this year. “Brokers and in as little as two hours compared to employer groups in our current service area tell us we’re an attractive option based current tests that take days to confirm on price and access to Sutter Health doctors and care centers,” said Sutter Health a diagnosis. The pilot program will run Plus CEO Steve Nolte. through June. San Francisco health offi- Sutter Health tested the HMO market in the 1990s with a plan called Omni cials confirmed reports of 114 TB cases Healthcare. It operated the HMO for four years before selling it to Blue Cross in in 2014 and 107 cases in 2013. 1999. Current members of Sutter Health Plus include the city of Sacramento and Sacramento County. —DOUG DESJARDINS « CONTINUED ON PAGE 5 » HIRE POWER: HEALTHFAX CLASSIFIED ADS WORK! PAGE 5 of 13 CALL 978-624-4594 For subscription services, call 800-753-0131 March 30, 2015

EVENTS IN BRIEFCONTINUED FROM PAGE 4 April 8-9. 2015 Statewide Telehealth Nurses at Sutter Santa Rosa Regional Hospital represented by the California »» Summit. Resort at Squaw Creek, Lake Nurses Association (CNA) voted to authorize a strike to provide leverage in con- Tahoe. A two-day forum focused on best tract negotiations with hospital officials. The vote gives the negotiating team rep- practices and new developments in the resenting nurses the authority to call for a strike but there is no strike planned at telehealth industry. Sponsored by the this time. The CNA and Santa Rosa Regional, which is owned by Sutter Health, have California Telehealth Network and the been negotiating a new contract since the last one expired in 2014 but are at odds Telehealth Resource Center. To register, over several issues including nurse staffing and medical benefits. please visit http://www.caltelehealth. org/2015-telehealth-summit »»Scripps Health announced that it will acquire Imaging Healthcare Specialists, a company that operates eight radiology centers in the San Diego area. According April 14. CMA Legislative Advocacy to a press release from Scripps Health, Imaging Healthcare will retain its name and Day. Sheraton Grand Sacramento. A autonomy and maintain its contracts with physicians at Radiology Medical Group one-day educational event for physi- | NUMBER 12 and Physicians Radiology Medical Group. The deal is expected to close by March cians,| VOLUMEmedical students,30 and healthcare March 31, 2014 31. “This acquisition expands Scripps’ ability to provide convenient access to radiol- advocates. Sponsored by the California ogy services for our patients across the county,” said Scripps president and CEO Medical Association. To register, please Chris Van Gorder. Imaging Healthcare Specialists CEO Jon M. Robins, MD, said visit https://www.cmanet.org/events/ that under the deal, the company “will be better positioned for positive population detail/?event=cma-legislative-advoca- health management across the community.” cy-day April 14-15. Annual Palliative Care »»SCAN Health Plan and insurer Cigna have partnered to provide SCAN’s Summit. Sacramento Hilton Arden West. Medicare Advantage plan to employer clients in California. According to a joint An educational forum for physicians, nurs- press release, the venture will provide “new options and streamlined benefit admin- es, and other healthcare providers focused istration for employers” and allow Cigna plan members to transition to SCAN’s on new trends and policies impacting pal- Medicare plan when they retire or become eligible for Medicare. “Through this alli- liative care. Sponsored by the Coalition for ance, we can now offer employer groups in California a full suite of benefit capa- Compassionate Care of California. To reg- bilities for active employees and retirees,” TOPsaid Chris STORIES De Rosa, president of the West ister, please visit http://coalitionccc.org/ Region for Cigna. SCAN’s Employer Group Waiver Plan will become available to training-events/annual-conference/ eligible Cigna plan members starting in JanuaryNumber 2016. Based of in Long Physicians Beach, SCAN in State has has about 170,000 Medicare Advantage planIncreased members in California 39% and Arizona Since. April 1993 17-19. California Society for Healthcare Attorneys (CHCF) showsAnnual the Meeting. The California Department of Public HealthMany (CDPH) areas received still have no new shortage reports of of physicians »» California HealthCareHyatt Foundation Regency Huntington Beach. An measles cases in its most recent reporting period,A new indicating study from that the the measles outbreak educational event with a focus on new could be coming to an end. No new reports of measles were received during the March estimates that number of physicians in California has increaseddevelopments: Surplus 39% over or theScarcity? and last upcoming two decades changes but in 13 to 20 reporting period and only one new thatcase not from all Marchregions 6 of to Californiathe 13, statewhich are boostedPhysicians benefiting California from the increase.health law. To register, please the current total to 133 cases. In a statement, theT heCDPH study said titled that “the outbreak will visit http://www.csha.info/events be considered over when 42 days have is elapsed”the number from the of physiciansday the last in thenew state case increased of 39% from 66,151 in 1993 to 91,775 California Healthfax Get your event listed in Healthfax! measles was reported. The measles outbreak beganin 2011, at aDisneyland percentage in that’s mid-December nearly double of the state’s 20% increase in population Published every Monday, during that period. But despite that increase, the reportE-mail shows the many details regions to: of the 2014copyrighted and eventually by HealthLeaders spread Media, to 13 a countiesdivision - and several other states. [email protected]. of BLR, 75 Sylvan St., Suite A-101, Danvers, state still have a shortage of physicians. The federal government recommends that communities have between 60 and MA 01923, and is transmitted solely to the sub - - scriber. Any unauthorized copying, duplication or- 80 primary care physicians for every 100,000 residents to ensure adequate access transmission is strictly prohibited. Annual sub to care and between 85 and 100 medical specialists for every 100,000 residents. scriptions are $179. For group and bulk subscrip In 2011, California met that requirement statewide with 64 primary care physi San tions, call 800-650-6787. cians for every 100,000 residents and exceeded it with 130 specialistsOrder forNow every CUSTOMER SERVICE: If youCENTER do not 100,000 residents. San E-mail Subscribers But the study showed sharp disparities in physician supply by region. The receive your copy of HealthFax, send had 86 primary care physicians and 175 specialists for every Francisco Bay [email protected] • 800.753.0131 GETrequest YOUR to: [email protected]. SUBSCRIPTIONiption questions, TODAY. GETa YOUR SUBSCRIPTION TODAY.100,000 residents in 2011, well abovewww.HcMarketPlace.com/california-healthfax the state average. On the flip side, the For renewals or other subscrBy fax: 866-592-7573. had only 48 primary care, a physiciansregion in Southern and 80 specialists California formade every up of please call: 800-650-6787. Joaquin Valley Inland Empire By e-mail: [email protected]. 100,000 residents. The counties, had only 43 primary care physicians and and San Bernardino EDITORIAL SUBMISSIONS con- Riverside To submit an item for consideration, By e-mail: 77 specialists for every 100,000 residents. - tact Doug Desjardins, Editor. “There are efforts underway, a senior to get program more physiciansofficer for tothe practice CHCF. “Butin those it’s going By phone: 760-696-3931. Robbin Gaines areas,” said [email protected]. For other questions,: contact 800-639-7477, Bob Wertz, ext. Managing 3456. to take a while.” One program provides doctors who recently graduated from medi Editor. By phone cal school with up to $105,000 in student loan payments in return for practicing in [email protected] By e-mail: an underserved area of California for three years. One trend in California’s favor is the percentage of medical school graduates ADVERTISING OPPORTUNITIESC a l i f o r n i a who choose to remain in California after they graduate. The study showed that To advertise in by Healthfax, please contact Susan 62% of students who attended medical school in California » remained in the state e - m a i l : s u s a n p @ h c p r o . c o m . « CONTINUED ON PAGE 2 By phone: 978-624-4594. objectives! Consulting.com Achieve your important Scott@Cebula 949.734.0910 Local, experienced talent for... Fair, All-inclusive Rates ¸Interim IT Leadership ¸ICD-10 Readiness & Remediation ¸Project Management (PMPs) ¸IT Strategic and Financial Planning TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 6 of 13 For subscription services, call 800-753-0131 March 30, 2015

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Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. We serve over 1,000,000 members in Riverside and San Bernardino counties in Medi-Cal,Cal MediConnect Plan, Healthy Kids and a Medicare Special Needs Plan. Our success is attributable to our Team who share the IEHP mission to organize the delivery of quality healthcare services to our members. Join our dedicated Team!

ACCOUNTING SUPERVISOR High School Diploma or equivalent required. Associate degree in Accounting preferred. Five (5) or more years experience in an accounts payable, accounts receivable or general accounting environment; minimum of three (3) years in a supervisory capacity. Intermediate to advance Microsoft Office skills (Excel, Word etc.). Experience with ERP systems Oracle a plus. BUYER III Bachelor’s degree in Business Administration or related field required. Professional certification from a national body (e.g. ISM or NIGP) is preferred. Five (5) years of purchasing related experience required. Governmental purchasing experience preferred; public works purchasing experience a plus. Ability to communicate clearly and effectively, including in a persuasive manner at times, with outside vendors as well as all levels of the IEHP team. FINANCIAL ANALYST Bachelor’s degree required. Minimum of one (1) year of Finance or five (5) years General Ledger experience. Experience in Managed Care preferred. Experience in developing complex reports using financial reporting software. Experience in statutory reporting a plus. Strong knowledge and demonstrative proficiency utilizing Microsoft Applications (Word, Excel, Access & PowerPoint). Strong understanding of accounting and financial principles and methodologies. Experience with SQL, Oracle and Hyperion a plus. Principles and practices of health care industry and strategies, health care systems, capitated risk contracting, provider network structures and risk sharing arrangements a plus. INPATIENT REVIEW NURSE MANAGER State of California RN License or LVN with a bachelor’s degree required. Possession of a bachelor’s degree referred. Possession of a valid California driver’s license and auto insurance. Under the direction of the UM Director-Inpatient, responsible for the oversight of the Inpatient Review Nurses. Hospital experience and three (3) or more years experience with medical groups and an in-depth knowledge of all aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis on Concurrent Review and utilization management. Self-starter and team player. Analytical skills, time management, and problem solving. Knowledge of Microsoft Applications required (Word, Excel). Must have a high degree of patience, excellent communication, interpersonal and organizational skills. Knowledge of evidence based clinical criteria and CCS. PHARMACY CALL CENTER & TRAINING MANAGER Bachelor’s degree preferred. Education requirement may be waived if candidate has extensive supervisory experience in a healthcare call center environment and training experience. California State Board of Pharmacy Technician License required. Three (3) years prior call center supervision. Two (2) years of training experience. Knowledgeable in call center supervisory applications and training modalities/tools. Ability to balance multiple projects and meet deadlines with high quality output. Five (5) or more years of healthcare call center experience with training supervision and working in a health care delivery setting. Proficient in Microsoft applications (Microsoft Word, Excel). Excellent written and verbal communication, interpersonal skills, ability to establish and maintain effective working relationships with others, ability to supervise and train team members strong organizational skills, detailed oriented, and sound decision making skills required. Experience in an HMO, managed care, Knowledge in Medi-Cal, Healthy Families, Healthy Kids, and Medicare Programs preferred. PHARMACY MEDICARE PART D ANALYST Bachelor’s degree required. CPA license desired. Minimum one (1) - three (3) years experience in Medicare Part D and analyzing Pharmacy data. CMS Financial reconciliation experience is required. Under the direction of the director of pharmaceutical services, the Medicare Part D analyst will be responsible for reviewing, understanding, and integrating processes related to Medicare Part D. The analyst will handle complex data projects, review regulations, and assist in project managing processes across departments. Duties related to this position include oversight of; support/resolution of PDE claims, accuracy of eligibility data, transaction data, cross department communication, and meeting all regulatory requirements. Proficient with Microsoft Applications with the emphasis on Excel and Access. Ability to interpret detailed data and develop accurate, meaningful and reliable reports for management while meeting ongoing deadlines. Excellent written, organizational, data entry and interpersonal skills required. TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 8 of 13 For subscription services, call 800-753-0131 March 30, 2015

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PHARMACY UTILIZATION MANAGER Pharm. D. from an accredited institution required. California State Board of Pharmacy, registered Pharmacist License. Five (5) or more years of individual or combined experience in clinical pharmacy setting, preferably in an HMO, Managed Care, or specialty Pharmacy setting. Clinical residency preferred. Under the direction of the Pharmacy Medical Director, the Pharmacy Utilization Manager is responsible for providing manager level management and leadership of the Financial and Utilization Unit. Responsible for the direction, coordination, implementation, and management of the financial and utilization programs. Knowledge related to Medicare Part D, PDE, utilization trends, budgeting, and financial forecasting preferred. PROVIDER AUDITOR Bachelor’s degree preferred. Possession of a valid California driver’s license and valid auto insurance. Four (4) years claims processing experience in a managed care environment, two (2) years claims auditing experience and two (2) years experience working with Providers. AAPC Certification a plus. Working knowledge of Medical Group and HMO operations, claims delegation, compliance and contract interpretation. Solid understanding of DMHC, DHCS, CMS, and MRMIB regulations for claims adjudication practices and procedures for Medi-Cal and Medicare claims. Working knowledge of audit processes and protocols, strong organizational skills, effective writing and communications skills and computer proficient. Ability to interact with all levels of management and establish and maintain strong business relationships with plan partners. QUALITY MANAGEMENT MANAGER Bachelor’s degree in business or health field, or a valid RN license issued by the State of California, required. Possession of a valid State of California driver’s license. Three (3) or more years experience in a Quality Assurance Program with a hospital or HMO. Microsoft applications (Microsoft Word, Excel, Access) skills required. Please apply on-line: https://ww3.iehp.org/en/about-iehp/careers/ INLAND EMPIRE HEALTH PLAN Rancho Cucamonga, CA Please visit our website at www.iehp.org

CLINICAL PHARMACIST – CDAG Req. #15-1716 CODING QUALITY SPECIALIST SR. Req. #15-1696, 15-1697 COMMUNITY SERVICES RN Req. #14-1519 DATA ANALYST SR. – HEDIS & MEDICARE STAR Apply Req. #14-1521, 15-1693, 15-1694 We’re rapidly growing … We have new and Now DATA ANALYST, SR – HEALTHCARE SERVICES Req. #15-1722 exciting opportunities for: DIRECTOR ACTUARIAL SERVICES Req. #14-1610 DIRECTOR CONSUMER INSIGHT Req. #15-1688 • Utilization Review RN FACILITY SITE REVIEW NURSE Req. #14-1660 HEALTHCARE INFORMATICS ANALYST II Req. #14-1588 • Medical Director MANAGER CLAIMS - AUDIT & RECOVERY Req. #15-1734 • Project Manager – Health Center Development MANAGER IT SECURITY Req. #15-1695 MEDICAL MANAGEMENT SPECIALIST (REMOTE) Req. #15-1717 • Human Resources Business Partner (HRBP) MEDICAL MANAGEMENT SPECIALIST – RN Req. #15-1703 • Healthcare Data Analyst NETWORK MANAGEMENT SPECIALIST Req. #15-1728 NURSE PRACTITIONER (STOCKTON, CA) Req. #15-1711 Visit our website regularly for updates on new positions! PHYSICIAN ASSISTANT (STOCKTON) Req. #15-1723 PROGRAMMER ANALYST II Req. #15-1738 Apply Now: www.culinaryhealthfund.org RECOVERY SPECIALIST Req. #15-1735 REG’L CONTRACT MGR – NETWORK MGMT Req. #14-1581 Competitive compensation and benefits including a fully SR. BUSINESS ANALYST – DIGITAL STRATEGY Req. #15-1726 funded employer paid pension plan, BCBS medical, SQL DATABASE ADMINISTRATOR Req. #14-1591 dental, vision, 401(K), Flex-Spending Account, 12 paid For more information, please visit our website at: holidays and generous PTO! http://www.scanhealthplan.com/careers/ TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 9 of 13 For subscription services, call 800-753-0131 March 30, 2015

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Gold Coast Health Plan is currently accepting HEALTHCARE PARTNERS MEDICAL GROUP, a division of DaVita applications for the following positions: HealthCare Partners, Inc. (DVA: NYSE), is a top-rated medical group and √ Director of Risk Management is widely recognized for its achievements in clinical excellence and patient √ IT Project Manager satisfaction. Since 1992, √ Manager of Provider Relations HealthCare Partners has been committed to developing innovative models of healthcare delivery that improve patients’ quality of life while contain- √ Clinical Program Manager – ing healthcare costs. HealthCare Partners manages and operates medical Disease Management groups and affiliated physician networks in Arizona, California, Nevada, √ Public Relations Manager Florida, New Mexico, and Colorado. As of Sept. 30, 2013, HealthCare √ Pharmacy Technician Partners provides integrated care management for approximately √ Health Education Program Supervisor 760,000 managed care patients. √ Administrative Assistant We are committed to bringing the benefits of coordinated care to our patients and to taking a leading role in the transformation of the national √ Compliance Specialist healthcare delivery system to assure quality,46839 access, and affordable care √ Claims Quality Assurance Analyst for all. If you’re looking to make a difference with a large, financially stable, well-recognized medical group, DaVitaHealthfax HealthCare Partners may √ Manager of Quality Improvement be the employer for you. 03/30/15 √ Cultural and Linguistics Specialist Immediate Care Management Opportunities:1/4 pg (3.65” x 4.25”) √ Outreach Coordinator √ Quality Improvement Data Analyst Manager, Regional Care Managementjlr RN Req. #17124 - Torrance All qualified candidates must submit an online application. Online applications Responsible for oversight, management, optimization of quality and full job descriptions can be found at: http://www.goldcoasthealthplan.org/about-us/careers.aspx improvement, utilization management, care management activities related to preadmission, ambulatory case management, and other health care delivery programs for Out of Area department.. Manage team members and daily operations of care management programs.

Manager, Regional Care Management RN Req. #14774 - Arcadia Responsible for the oversight, management and optimization of all quality improvement, utilization management and care manage- Care Management Supervisor - RN ment activities as it relates to pre-admission, ambulatory case (Merced) management, inpatient, social service, home health, health educa- New! $15,000 sign-on bonus! tion, behavioral health and other health care delivery programs Under direction this position supervises the daily activities of the Care within Health Care Partners Medical Group. Manages staff directly Management staff; coordinates and implements effective and efficient Care Management processes which includes Complex Care Management, Children’s Care Management, Medical Social Work and care coordination; Manager, Regional Care Management RN and performs other duties as assigned. Req. #15155 - Chatsworth Responsible for the oversight, management and optimization of This position requires a current unrestricted Registered Nurse license in CA, and a Bachelor’s degree in Nursing (BSN) or a closely related field all quality improvement, utilization management and care man- preferred; a minimum of five (5) years of experience in a patient care setting agement activities as it relates to pre-admission, ambulatory case required; at least one (1) year of case management experience; two (2) management, inpatient, social service, home health, health educa- years of experience as a full-time supervisor; or an equivalent combination of education and experience that would provide the required knowledge, tion, behavioral health and other health care delivery programs skills and abilities may be qualifying; and Critical Care, Emergency Room, within Health Care Partners Medical Group. Manages staff Telemetry, or Medical Surgical, unit patient care setting experience preferred. directly and responsible for the day-to-day operations of the care management programs. For a complete position description and to apply online, visit our careers website at For immediate consideration and to view additional Care www.ccah-alliance.org/careers.html Management opportunities; please visit our company website at www.healthcarepartners.com This is an exempt position. Salary range is $66,227 - $121,700/annual.

“Creating Healthcare Solutions” TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 10 of 13 For subscription services, call 800-753-0131 March 30, 2015

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Compliance Officer Executive level position reporting to the CEO and the Board of Directors The position serves as the Compliance Officer for the organization and is responsible for coordinating and communicating assigned compliance activities and programs. Implements, monitors compliance program. Ensures company meets state, federal regulatory, contractual requirements. Interacts with CalOptima executive and management, health network management, legal counsel, state, federal representatives and others. Supervises Compliance department staff. Responsible for internal compliance, auditing activities; developing, implementing annual compliance plan for company business lines; regular reporting to CEO and Board members. Responsible for oversight for delivery of health care services via subcontracts with provider network at the subcontracting health plan and direct provider levels. The position oversees a comprehensive and complex program, including compliance professionals with expertise and responsibilities for the following areas: Medicare and Medi-Cal compliance, audit and monitoring, fraud, waste and abuse, special investigations, privacy, participating provider group oversight, policies and procedures, and organization-wide compliance training.

Position Responsibilities • Provide leadership in coordination with others in the organization for • Oversee and monitor all aspects of the implementation of the compli- the implementation of all HIPAA development activities. ance program, including an annual schedule of compliance activities. • Proactively work with managers to improve organizational effectiveness. • Provide ongoing reporting on activities to the Chief Executive Officer, and to the organization’s Finance and Audit Committee of the Board. • Act as the liaison between CalOptima and OIG for fraud and abuse issues. • Develop and implement training programs for internal staff and subcon- • Maintain CalOptima compliance policies and ensures regular policy review. tractors such as Code of Conduct, Fraud, Waste, and Abuse, Privacy and Information Security. Experience & Education • Ensure compliance with new laws, regulations and directives. Develop inter- • Bachelor’s degree in Health Care Administration or other related field nal processes to coordinate activities with departments and functions. required. • Develop and implement internal compliance reviews and monitor activities (including financial and operational compliance reviews). Conduct • Master’s degree in Health Care Administration, Business Administration, routine internal audits to include, but not limited to, the claims adjudica- Public Administration, Clinical Area, or Law and Health Care Compliance tion process and member rights. certification preferred. • Develop and implement external compliance reviews on subcontractors, • 10+ years of experience in a leadership role in a managed care organization. contracted provider groups, and third party vendors. • Develop policies and procedures that encourage management, • Medi-Cal and Medicare experience highly preferred. employees, and members to report any suspected fraud. Medical Case Manager (Ambulatory RN) 20 Openings due to New Program Care Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima members. The Case Manager facilitates communication and coordination among all participants of the health care team and the member to ensure that the services are pro- vided to promote quality cost-effective outcomes. The Ambulatory Case Manager provides intensive case management in a process that includes assessment, planning, facilitation, implementation, coordination, monitoring and evaluation of the member’s needs.

Position Responsibilities • Prepare and maintain appropriate documentation of patient care and • Performs comprehensive, disease specific, clinical assessment of all progress within the care plan. identified cases including assessment of member’s physical, functional, • Act as an advocate in the client’s best interest for necessary funding, social and psychological status, cultural and linguistic needs and assessment of caregiver resources and available benefits. treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals. • Development and implementation of a member specific care plan which includes problems, interventions and goals. • Develop policies, procedures, desktop procedures, assessments and • Schedule follow-up to assess progress towards goals and identify barri- referral templates to facilitate the implementation of and compliance ers to meeting goals. with new case management programs or requirements. • Communication with member’s physicians, specialists, community agen- • Develop processes for oversight and reporting in compliance with new cies and vendors to ensure coordination of services. case management programs and requirements. • Follows CalOptima’s protocol for documenting all case interventions. • Participate in Grand Rounds Case Conference. Experience & Education • Facilitate interdisciplinary care team meetings (ICT)’s as indicated. Registered Nurse with an AS, BS or higher degree and current CA • Work collaboratively with interdepartmental staff, as needed, in case professional license. resolution. • 5 + years clinical experience, managed care experience preferred. • Identifies cases needing Supervisor, Manager, Director or Medical Director review or input and routes accordingly. • CCM certificate preferred. • Closes cases according to defined case closure procedure in a timely • Bilingual skills in English/Spanish, English/Vietnamese, English/Korean, manner, and in accordance with established guidelines. English/Farsi or English/Cantonese highly desirable. See website for job details and to apply: https://www.caloptima.org/en/Careers.aspx. CalOptima offers an excellent work environment, APPLY HERE including a highly competitive benefits package. TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 11 of 13 For subscription services, call 800-753-0131 March 30, 2015

FEATURED CAREER OPPORTUNITIES

Kern Health Systems (KHS) is the largest health plan in Kern County, SCRIPPS HEALTH PLAN SERVICES is hiring the following positions: serving over 192,000 local members. We are currently seeking the following positions to join our team! At KHS, we are dedicated to improving the health status of our members through an integrated FINANCIAL ANALYST SR - Payer Relations managed healthcare delivery system. This is an excellent opportunity Full-Time – Day to join an organization with excellent benefits, career advancement, and professional growth opportunities. Job Summary: Provides management, accounting and analysis of all managed • Claims Supervisor • Data Analyst III care contracts to all levels of management at Scripps Health to • Payroll Supervisor • Database Administrator III support its negotiating position. The presentation of information • Pharmacist • UM Clinical Intake includes data, applicable analysis and recommendations to create Coordinator RN I appropriate negotiating positions through the use of financial • Provider Relations Manager • Claims Examiner accounting, budgeting and other systems when necessary.

Benefits: Experience/Specialized Skills: We have an excellent benefit package which includes: health insur- 3 or more years of experience in broad-based analytical, managed ance, dental, life, Vision, 457(b) and 401(a) Plan, PTO and EIB, care payor or provider environment; experience in statistical CalPERS and other company benefits. analysis; or any combination of education and experience, which If you want to learn more about these great opportunities please would provide an equivalent background. visit our web-site at kernhealthsystems.com or come by our Human Resources Department, 9700 Stockdale Hwy. Bakersfield, CA 93311, Fax 661-664-4310, business hours are Monday-Friday 8:00am to Required Education/Course(s)/Training: 5:00pm-email resume to: [email protected]. A Bachelor’s degree required. Master’s degree preferred. “Kern Health Systems is a tobacco-free facility” To apply online please visit http://www.scripps.org/about-us__careers NOTE: As a condition of employment, a satisfactory drug test and background check is required. E.O.E and search by Req. #1001432.

We are currently looking for a Director to oversee our exciting Regional Referral Program! The Director will promote and maintain positive physician relations and hospital partnerships, provide proactive leadership for associated physicians, specialty physicians, and the overall program. Do you have a history of building strong physician relationships, along with sales experience? If so, than this may be a perfect position for you! The hospital Ministries of St. Joseph Health represent a regional destina- tion dedicated to meeting the healthcare needs of Northern California communities with compassionate care, progressive treatments, and advanced specialty services. The Regional Referral Program expands the Ministries’ regional presence to communities with limited access to specialty physicians, advanced medical and surgical care, including Trauma. The program’s scope includes an acute and non-acute presence in the primary and secondary services area. These areas include Sonoma, Mendocino, Napa, Humboldt and Lake Counties. Requirements: • Bachelor’s degree, Master’s preferred • 5 years’ experience in physician relations, sales, managing a clinical practice, service line program or a combination of thereof

To apply, please visit our career site at: http://www.stjoesonoma.org/Careers.aspx TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 12 of 13 For subscription services, call 800-753-0131 March 30, 2015

FEATURED CAREER OPPORTUNITIES

Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

VICE PRESIDENT, INTEGRATED CARE CLAIMS ANALYST We are seeking an executive who will be responsible for leading the development This analyst role will perform analysis of claims to ensure accuracy of payment. This and expansion of Humana’s relationships with delegated risk entities (primarily is accomplished both in-house and by contracting vendors with expertise in their IPAs) across California. Based within our Irvine or Torrance office, this role reports areas. The ideal candidate will possess previous claims processing experience within to the California Market President and serves as the primary leader for the expan- the healthcare industry. Req. # 131237. sion of our Integrated Care model across the state. This is a strategic, innovative and results-oriented role with broad responsibility for provider group performance PROJECT MANAGER metrics, provider relations service strategy, medical management relationships, As a Project Manager you will manage, analyze, strategize, create, improve, process management and quality (Stars). and implement new operational processes across various functional areas of Our ideal candidate will bring a combination of provider and managed care Humana and the CA market. You will evaluate the effects of process changes leadership experience to this role, with deep experience in building relationships by quantitatively and qualitatively measuring them against internal and external with physician executives and other healthcare leaders in IPA environments. benchmarks. In addition, you will oversee the application of project manage- Prior business leadership with financial accountability is required, as insight ment methodology during all phases of the project cycle, with responsibilities gained from experience in functions such as provider network development, including project design, scope management, cost control, and both quality and IPA administration or oversight, Medicare risk contracting, and clinical quality. performance reporting. Req. # 139123 Please send qualifications to [email protected] BUSINESS ANALYST FINANCE DIRECTOR, CA SENIOR PRODUCTS Based within our Walnut Creek office, this analyst role will provide research Our search is focused on identifying an executive candidate who will serve as and analytical support to a team of associates during the design, development the #1 Financial Leader for Medicare Advantage in the California Market. Based and implementation of Humana products. The position will analyze project within our Irvine or Torrance office, this role reports to the California Market requests, maintain timelines, determine requirements and feasibility, and docu- President, and contributes to the financial strategy, integrity and profitability ment process workflow for all services. The ideal candidate will possess previ- of the market. As a member of the California Senior Leadership Team, this role ous healthcare insurance experience, and a bachelor’s degree in business or a will provide direction and administration of all financial aspects of programs, related field. Req. # 140589 products and services, and have responsibility for 2-4 direct reports and a team of 12 or more associates. RAF/MRA MANAGER The ideal candidate will possess broad managed care financial leadership This manager role will oversee day to day operations, process improvements experience including prior responsibility for directing the strategic financial and achieve performance metrics for a fast paced work environment; Actively business planning, financial analysis/reporting and MA bid development for a coordinating with STARS team, Provider Relations/Contracting with key pro- managed care Medicare/Medicaid health insurer. Please send qualifications to viders to improve risk scores; Develop team members and create department [email protected] process flows; Develop, validate and implement data mining strategies for new processes; Oversee encounter data capture and submission from MRA perspec- NON-CLINICAL SPECIALIST tive. Present HCC/RAF performance results and findings regularly to delegated risk groups. Responsible for provider educational activities and projects. Please As a Specialist, you will contribute to the success of Humana’s business strategy by send qualifications to [email protected] collecting broad based information and gathering resources and data in order to arm the team with the tools necessary to enhance consumer engagement, choice, RAF/MRA PROCESS CONSULTANT and trust. Req. #138487 This consultant role will require project management. As a Process Consultant you UTILIZATION MANAGEMENT SPECIALIST will manage, create, improve and implement new processes across MRA and the delegated providers/group. This position will be responsible for projects across This is a telephonic position making outbound calls to facilities, updating electronic delegated providers/ risk groups in the region including provider education, data authorizations, generating letters, and working in the hub of our utilization manage- analysis & audits. Serves as a liaison to clients (internal/external) by managing and ment team. As a Utilization Management Specialist you will: make outbound calls to implementing new processes, and formulating enhancements and improvements to providers to obtain clinical information, update electronic authorizations, using your existing processes; and as a focal point for all cross functional areas. Req. # 138303 analytical skills to manage your caseload and pull reports, document your conversa- tions with providers, update the status of authorizations, field inbound calls to the region and support the clinical team. Req. #138379

To apply for these and other career opportunities, please visit http://careers.humana.com. Search for the Requisition Number listed above or send resume as noted in the job description. TO PLACE A LISTING, PLEASE CALL 978-624-4594 PAGE 13 of 13 For subscription services, call 800-753-0131 March 30, 2015

FEATURED CAREER OPPORTUNITIES

CLINICAL PERFORMANCE IMPROVEMENT CONSULTANT The Performance Improvement Consultant will be accountable for developing and maintaining key business relationships and optimize business results. This is a work from home opportunity. The ideal candidate will possess a background in provider education, field services, knowledge of the Central CA market, experience in HEDIS and Member Perception- CAHPS/HOS. The position will report to the Star Quality Director. Req # 139549. LEAD MEDICAL DIRECTOR - NORTHERN CALIFORNIA The Lead Medical Director will collaborate with other health care givers in reviewing actual and proposed medical care services against established CMS, DOI, and other nationally recognized, accepted guidelines. The position will Provide daily support to Medical Directors in CA Region; Develop, maintain, assure compliance with physician review policies and procedures; Support collaborative relationships with physicians, large provider groups, hospitals, and others; Examine clinical programs information to identify members for specific case management, disease management activities or interventions by utilizing established screening criteria. Requirements include Board Certified MD/DO in ABMS Medical Specialty; Active unrestricted license and the willingness to obtain additional licenses as required; 5 years of established clinical experience. Req # 140100

To apply for these and other career opportunities, please visit http://careers.humana.com. Search for the Requisition Number listed above or send resume as noted in the job description.