top StoriES State Lawmakers Crafting plan for …promos.hcpro.com/pdf/CA_HF_081312.pdfseeks Chapter 9 bankruptcy pro-tection from creditors. A group of retirees filed a motion to block

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August 13, 2012 | VoluME 19 | nuMBEr 31

t o p S t o r i E S

State Lawmakers Crafting plan for Essential Health BenefitsConcept modeled on coverage provided in Kaiser HMoState legislators are scheduled to act on two bills this month that could help estab-lish the essential health benefits insurance companies will need to provide as basic coverage on policies in the individual and small group market starting in 2014.

Senate Bill 951 authored by state Sen. Ed Hernandez (D-West Covina) and Assembly Bill 1461 by assembly member Bill Monning (D-Carmel) would provide insurers with more clarity about basic coverage that will be required under the patient protection and Affordable Care Act (PPACA).

SB 951 would require insurers to provide coverage for a number of services currently not required under all health plans, including pediatric vision care and mental health services. Hernandez said the bill will put an end to the sale of “junk insurance” and ensure that insurers sell only “quality products that provide con-sumers with robust coverage by setting a floor that products for sale must meet.”

AB 1461 would prevent insurers from denying coverage due to pre-existing health conditions and limit the conditions that insurers use to determine premi-ums. The bill would “allow insurers to use only age, geographic region, and family size for the purpose of establishing rates for individual health plans.”

The California Association of Health plans (CAHP) has not taken a posi-tion on SB 951 but is opposed to AB 1461. A CAHP analysis of the bill notes that it does not include tobacco use as one of the factors that would allow insurers to raise rates on a policyholder. It states that the PPACA establishes a number of rating limitations on health plans but that it “allows for higher premiums in the individual market for people that use tobacco products.”

“We’re saying that, if the state is going to enact legislation connected to healthcare reform, the legislation should be consistent with provisions of the ACA,” said CAHP spokesperson Nicole Kasabian Evans. She added that preventing insurers from raising premiums on policyholders who smoke ciga-rettes or use tobacco in other ways would “require non-smokers to pay for the habit and choices of smokers.”

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» The California Department of public Health (CDPH) received its first report this year of a fatality from West Nile virus. The victim was identified as an 88-year-old woman who lived in Kern County. “This unfortunate death reminds us that we must protect our-selves from mosquito bites to prevent West nile virus and other mosquito- borne infections,” said ron Chapman, MD, director of the CDPH. So far in 2012, there have been 10 reported cases of West nile virus in California in five counties. At this point in 2011, there were seven reported cases and no deaths. The CDPH recommends that, to avoid contracting West nile virus, resi-dents should wear mosquito repellent from dusk through dawn and eliminate pools of standing water near homes that can serve as a breeding ground for mosquito eggs.

» The entire 12-member board of direc-tors for the Sonoma Valley Hospital Foundation resigned last month amid a dispute over how to raise money to fund the hospital’s planned expan-sion. According to a report in the Press Democrat, board members said they felt “dominated” by executives at Sonoma Valley Hospital. “They’re trying to tell us how to operate,” said board mem-ber Carolyn Stone. “We operate accord-ing to our bylaws.” Bonnie Durrance, a spokesperson for Sonoma Valley Hospital, said that “now, it’s up to the hospital to put in place a seamless transition into whatever the next form of fundraising will be.” Sonoma Valley is attempting to raise $7 million to complete a $39 million expansion of the 83-bed hospital.

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Monning said AB 1461 does not include tobacco use “because it could result in pricing smokers out of the insurance market.” He said a “preferred approach is to ensure that smokers have health insurance coverage and can be educated by healthcare providers about the health effects of smoking and encouraged to take part in tobacco cessation programs.”

AB 1461 was approved by the state Assembly and is awaiting action in the Senate Appropriations Committee. SB 951 was approved by the state Senate and is awaiting action in the Assembly Appropriations Committee.

State lawmakers are using the coverage provided under the Kaiser Foundation Health plan Group HMo as a benchmark for the state’s essential health benefits package. The Kaiser plan provides coverage in nearly all of the 10 areas of care mandated by federal healthcare reform, which are ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilita-tive services and devices, laboratory services, preventive and wellness services, and pediatric services including oral and vision care.

Individual states have been given some discretion to interpret the scope of those services. For instance, there’s currently some dispute in California over how basic coverage for rehabilitative services will be defined, given the wide scope of services available under that umbrella.

“Federal healthcare reform mandates coverage in 10 specific areas but gives states some leeway within those areas,” said Anthony Wright, executive director of advocacy group Health Access California. “But, in the end, the goal is to remove the ‘fear of the fine print’ in health plans and give people the peace of mind knowing that, if they get sick, their insurance plan will cover them.”—Doug DesjarDins

State in talks with Anthem Blue Cross over reimbursement Disputeinsurer ordered to stop collection effortsAnthem Blue Cross and state regulators are in talks to resolve a dispute over Anthem’s efforts to collect millions of dollars in reimbursements from hundreds of healthcare providers.

Anthem has been attempting to collect reimbursements from providers for medical claims it contends were overpaid. In July, the state Department of Managed Health Care (DMHC) ordered Anthem to stop its effort to col-lect on many of those claims, citing a state law that allows health plans to

Essential Health Benefits cont.

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» A federal bankruptcy judge has rejected a request to block the city of Stockton from cutting healthcare benefits for retired city employees while it’s in bankruptcy proceedings. Approximately 1,000 retired city employees were informed in July that they would need to pay their health coverage premiums while the city seeks Chapter 9 bankruptcy pro-tection from creditors. A group of retirees filed a motion to block the effort but federal judge Christopher Klein issued an order denying the request for a temporary restraining order against the city of Stockton. Attorneys for the city argued that it needs to reduce spending in all areas while it prepares a bankruptcy restructuring plan. on June 29, the city of 290,000 filed for bankruptcy protec-tion when it was unable to restructure more than $700 million in debt with creditors.

» A study conducted by researchers at the University of California, San Francisco found that hospital emer-gency departments in areas with large ethnic minority populations tend to be overcrowded and have a higher rate of ambulance diversions. The study examined ambulance services at 200 hospitals in the state and found hospi-tals serving a high number of minority patients had to implement ambulance diversion an average of 306 hours per year compared to 75 hours per year for hospitals with fewer minorities. Ambulance diversions occur when an emergency department becomes too crowded to accept additional patients,




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seek reimbursements on claims only within a year of the original payment date. In order to collect on claims more than one year old, state law requires health plans to show the overpayments were the result of fraud or misrepresen-tation by the provider.

Anthem said it’s attempting to collect on overpayments that were the result of double-billing and contends that guidelines issued by the American Medical Association (AMA) allow health plans to pursue reimbursements beyond the state’s one-year limit.

The dispute stems from an investigation the DMHC made into Anthem’s collection efforts at the request of the California Medical Association (CMA), which said dozens of its members had complained about Anthem’s attempts to collect overpayments on claims that were more than one year old. The DMHC investigation found that, between 2008 and 2011, Anthem attempted to collect on overpayments from at least 535 providers in the state for claims more than one year old.

Following the investigation, the DMHC ordered Anthem to stop its collection efforts, noting that Anthem did not provide evidence of fraud or misrepresenta-tion in any of the cases it was seeking payments for. “Health plans have one year to request reimbursement for medical claims they determine were overpaid,” said DMHC director Brent Barnhart. “Anthem’s recoupment practices violate California law and are unfair to providers who are acting in good faith.”

In a statement, CMA President James t. Hay said that Anthem’s practices “interfered with physicians trying to run their practices and also increase the overall cost of care.” The CMA encouraged the DMHC to “take further action, including imposing heavy fines to deter future abuses.” A spokesperson for the CMA said the group has not received any recent complaints from physicians about collection attempts by Anthem.

DMHC spokesperson Marta Green said state officials are involved in talks with Anthem Blue Cross to resolve the issue. “We are in active conversations with Anthem regarding a resolution,” said green. Anthem declined to comment on its negotiations with the state but defended its previous efforts to collect reimbursements from providers.

“Anthem Blue Cross believes medical providers should be compensated for their services but should not receive payment twice for the same procedure,” said Anthem spokesman Darrel Ng in a prepared statement. “Consistent with AMA guidelines, Anthem Blue Cross has sought reimbursement for these over-payments where medical providers have filed for and received over payments due to double-billing. We will closely examine the action of the DMHC and consider our options.” —Doug DesjarDins


Anthem Blue Cross cont.

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forcing patients to be transported to the next closest emergency depart-ment. “Because ambulances typi-cally transport patients needing true emergency care, diversions reroute the neediest patients away from their nearest hospital, representing a fail-ure of the system to provide intended care,” the authors of the study wrote. The study appears in the August issue of the publication Health Affairs.

» Workers completed the steelwork on the new Sutter Medical Center in Santa rosa this month to keep the hospital on schedule for an opening in late 2014. The new hospital will fea-ture 82 beds with private rooms along with 24 outpatient beds. Mike Cohill, president of Sutter Health’s West Bay region, called the completion of steelwork a “significant milestone.” Construction work on the $284 million hospital began in 2010.

» A woman was arrested for alleg-edly trying to steal a newborn baby from Garden Grove Hospital and Medical Center. According to garden grove police, the woman “attempted to remove a newborn baby girl” from the hospital by hiding the child in a tote bag. The report noted that the baby had an electronic monitor on “that signaled an alarm as soon as the woman tried to exit the hospi-tal. An alert employee of the hospi-tal heard the alarm go off and con-fronted the woman and contained her until we arrived at the location.” The woman—identified as a 48-year-old garden grove resident—was wearing




Dignity Health in talks to integrate Hospitals with UC San FranciscoHospital systems discussing integrated care plan Dignity Health and the University of California, San Francisco Medical Center are planning to launch an integrated care program that would link some Dignity Health hospitals with the academic medical center.

Though details of the program are still being worked out, both sides signed a memorandum of understanding in August for a partnership that would allow both hospital systems to integrate care. The memorandum provides only a broad outline of what the plan will eventually involve.

“We’ve just started talking and anticipate that we’ll have something more formal worked out by the end of the fiscal year,” said tricia Griffin, director of media relations and public affairs for Dignity Health, which operates 32 hospitals in California and four each in Arizona and Nevada.

The memorandum states that both organizations are “currently evaluating the viability and design of an integrated network, which would include uC San Francisco’s parnassus, Mount Zion, and Mission Bay campuses along with Dignity Health’s Saint Francis Memorial Hospital and St. Mary’s Medical Center.” The statement notes that the collaboration “does not involve a merger or an acquisition.”

Saint Francis is a 359-bed acute care hospital and St. Mary’s a 403-bed acute care hospital both located in San Francisco. UCSF Medical Center at parnassus is an acute care hospital that’s also home to Benioff Children’s Hospital. uCSF Medical Center at Mount Zion is a complex of specialty care, oncology, and surgical centers and the uCSF Mission Bay campus, which is cur-rently under construction, will include a 283-bed medical center and a new Benioff Children’s Hospital when it opens in 2015.

The memorandum said the goal of the project is to “bring together the academic, research, education, and quaternary care strengths of uCSF with the community-based primary and secondary care expertise of Dignity Health to build a unified healthcare delivery system in San Francisco.” In addition, the collaboration has goals similar to an ACo with plans to deliver “higher quality healthcare at lower costs as well as to provide physicians, patients and employ-ers in San Francisco with an alternative choice for care.”

Dignity Health and uCSF have collaborated on a number of projects in the region. They helped create and implement Healthy San Francisco—a health plan that insures low- and middle-income residents—and they collaborated on the formation of Glide Health Clinic, a free clinic in San Francisco that serves the uninsured. —Doug DesjarDins


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hospital scrubs and had a visitor’s pass at the time of the incident. Police have not established a motive for the attempted abduction.

» California pacific Medical Center (CPMC) has dismissed 120 consultants who had been working on plans for a new $2.5 billion medical campus for downtown San Francisco. CPMC said that dozens of architects, engineers, and planners will not be needed again until there’s more certainty about the project, which is on hold until november while a mediator attempts to work out a dispute between CPMC and the city of San Francisco about keeping the city’s safety-net hospital—St. Luke’s Hospital—open for at least 20 years. A spokesman said CPMC was paying the con-sultants a total of nearly $3 million a month for their services. San Francisco city officials are scheduled to meet on nov. 20 to vote on a development plan for the project, which would build a 555-bed hospital and seven-story medical office build-ing in downtown San Francisco.

» Salinas Valley Memorial Hospital has declined a proposed merger with Natividad Medical Center. Jim Gattis, president of the Salinas Valley Memorial Health System board of directors, said the proposal “did not meet the needs of our organization at this time.” natividad proposed the merger between the two Salinas-based hospitals, suggesting the merger would produce $553 million in additional revenue and savings over the next decade. In a statement, natividad Medical Center CEo Harry Weis said “a significant opportunity has been lost for our community.”

» The California Department of public Health (CDPH) has issued a citation and a fine of $80,000 against Fidelity Heath Care following an investigation into the death of a resident. The CDPH investigation involved a 2011 incident in which a resident of a Fidelity Health Care nursing home located in El Monte, “wandered out of the facility and was later found dead on the freeway.” The investigation found the facility “failed to provide a safe environment and adequate supervision, which resulted in the death of a resident.” Executives at Fidelity Health Care could not be reached for comment.

» The state Senate Appropriations Committee approved a bill that would require a parent or guardian seeking a personal belief exemption to prevent a child from receiving a vaccination to meet with a healthcare professional first. Assembly Bill 2109 authored by richard pan, MD, (D-Sacramento) is designed to ensure that a parent or guardian is informed of the risks involved in having the child not receive the recommended immunization. The bill is sponsored by the California Medical Association, which says AB 2109 “preserves a parent’s option to exempt their child from immunizations but ensures that such a deci-sion is an informed one and that the parent is aware of the individual and public health risks of not immunizing their child.” The bill will now go to the Senate floor for a vote.

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Aug. 19-21. Western Claim Conference. renaissance Esmeralda resort. Indian Wells. An educational conference with a focus on new developments in billing issues, legal issues, and the latest tech-nologies affecting claims operations. To register, please visit http://www.westernclaimconference.com/index.php?rule=conference.invitation

Sept. 9-11. HFMA Fall Conference: Southern California and San Diego Chapters. grand Champions resort, Indian Wells. A gathering of healthcare professionals with a focus on accountable care organizations and other cost-saving initiatives. Sponsored by the Healthcare Financial Management Association. To register, please visit http://www.hfma-cafallconf.org/

Sept. 11-15. Emergency Nurses Association Annual Conference. San Diego Convention Center. A four-day con-ference and exhibition featuring seminars and educational sessions to help nurses expand their knowledge and skill sets. To register, please visit http://www.ena.org/coursesandeducation/conferences/annual/2012/Pages/Default.aspx

Sept. 28-30. rural Healthcare Conference 2012. granlibakken resort, lake Tahoe. A three-day conference for rural health professionals with a focus on best practices and new technologies designed to improve healthcare delivery in rural areas. To register, please visit http://www.achd.org/upcomingevents.php

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senior product Manager (Cerritos, CA)

The Senior product Manager is accountable for leading the development and implementation of market strategies and competitive product/benefit offerings for CareMore. Education and/or Experience: Bachelor’s Degree (or equivalent experience), Masters preferred. Certificates, Licenses, Registrations: pMp desired. Other Qualifications: 10 years of managed care experience required, with a successful track record in two or more of the following areas: product development, product management, business development, strategic planning, or market management. experience orga-nizing, leading and successfully completing Health plan related projects or implementations (5+ years experience preferred). Knowledge of CMS part C and D requirements and Medicaid experience preferred.

prograM director, clinical expansions (Cerritos, CA)

This position will be responsible for managing the expansion of CareMore’s clinical model in new markets. This includes facilitation and oversight of expansion project plans, development and execution of initiatives to support replication and scalability, and partnering with the Senior Medical Officer to integrate the clinical model with new provider partners. Education and/or Experience: Bachelor’s degree required; Master’s degree preferred. 7-10 years in a program/project director and manager role, or: a Network Operations role directly responsible for execution of large scale change efforts. 5 + years health care experience.

clinical instructional designer (Cerritos, CA)

The Clinical Instructional Designer is responsible for analyzing, design-ing, developing, implementing, evaluating, and facilitating comprehen-sive learning solutions to develop training that supports the delivery of the CareMore model for diverse clinical teams within CareMore. Clinical teams include physicians, Nurse practitioners, Case Management, Medical assistants, and Clinical Department educators. Work inde-pendently as a part of the Clinical Operations Department, which also includes program Managers. The role of the Clinical Operations Department is to assist CareMore’s Clinical Teams to: develop and implement new systems, clinical programs, and work processes; improve operating infrastructure where needed; and roll out market expansions. Education and/or Experience: Bachelor’s degree in related field or com-bination of education and experience. Master’s degree strongly preferred. Minimum of 2 years of training and development experience. aSTD certificates a plus. 2 years of experience working with physicians, Nurse practitioners, or other Health Care professionals.

touch nurse practitioner (Phoenix, AZ / Tucson, AZ / San Jose, CA)

The Nurse practitioner for our “Touch” program (institutional special needs plan), ensures effective and efficient treatment of our Touch members. This individual will be responsible for managing patient care at multiple facili-ties through the implementation of cohesive and efficient processes, with emphasis to include patient and family satisfaction and physician and facil-ity support. This individual provides general medical care and treatment to members in institutionalized settings such as nursing homes, assisted livings, or board & care facilities, under the direction of the physician. Education and/or Experience: Master’s degree in Nursing with empha-

sis in Family, adult, or gerontological practice. Certificates, Licenses, Registrations: Current registered nursing license and Nurse practitioner license in good standing with the state in which you are applying.

hospitalist (Corona, CA / Los Angeles, CA / High Desert, CA / Riverside, CA

Upland, CA / Tucson, AZ / Las Vegas, NV)The Hospitalist provides Internal Medicine Services to patients. Responsibilities include: Round in the hospital in the mornings and sees an average of 6 to 10 patients. Conference calls with Case Managers to review patients, and discuss the discharge needs and plans. admit the patients from the eR in the afternoon (usually 2 to 4 patients), if they are assigned ‘float’ position for the given day. Work with Case Managers in transfer-ring the patients from ‘out of area’ hospitals into network hospitals. See patients in the CareMore Care Center (CCC). all patients discharged from the hospital are seen by the Hospitalists in the clinic until they are stabilized. patients with falls are assessed. pre operative clearance is done on patients undergoing surgeries requiring general and spinal anesthesia. assist Nurse practitioners by reviewing the cases with them. See the ‘skilled’ patients in the SNFs. These patients are seen once a week until they remain skilled, which is normally from 1 to 2 weeks. attend the SNF meetings once a week to review the cases. Education and/or Experience: Internal Medicine Residency, Medical Doctorate, and minimum of 2-3 years of Hospitalist experience preferred. Bilingual Spanish preferred. Certificates, Licenses, Registrations: Medical License in the state in which you are applying, Dea license. Must be board-certified or board eligible in specialty.

lead touch nurse practitioner (Tucson, AZ / Scottsdale, AZ)

The Lead Touch Nurse practitioner is a critical member of the Touch team ensuring effective and efficient treatment of our members in medi-cal facilities such as the skilled nursing facility, assisted living facility, or board & care. This individual will be responsible for managing multiple facilities through the implementation of cohesive and efficient processes, with key emphases to include patient and family satisfaction, physician support systems and smooth operations. This individual will be assisting with developing the local market. This individual will be responsible to hire and lead the Touch Nurse practitioners in their region of respon-sibility. Education and/or Experience: Master’s Degree in Nursing with clinical emphasis for Nurse practitioner. 1 year related experi-ence and/or training in related field preferred. Certificates, Licenses, Registrations: Current registered nursing license and nurse practitioner license in good standing with the state in which they are practicing. Other Qualifications: Furnishing number with the state in which they are practicing, preferred. Dea number, preferred.

nurse practitioner (Corona, CA / Modesto, CA / Downey, CA / San Bernardino, CA / San Jose, CA

Upland, CA / Tucson, AZ / Scottsdale, AZ)CareMore’s Nurse practitioners are the lead care managers for patients with chronic conditions. They provide exceptional care to our members in our Care Centers, and other care environments. Education and/or Experience: Masters Degree in Nursing required. Certificates, Licenses, Registrations: Current Np certification, RN license, Furnishing and Dea licensure in good standing as required in the state in which you are applying.

chief actuary (Cerritos, CA)

The Chief actuary is responsible for providing the leadership, pro-cess, and direction of actuarial projects within the actuarial Services department. The Chief actuary will report to the Vp of actuarial and Healthcare economics and is responsible for all actuarial functions including the Medicare Bid process, actuarial pricing, trend studies, as





well as revenue and healthcare cost forecasting. Education and/or Experience: Must have background in health care or managed care and a strong understanding of the Medicare business. extensive expe-rience organizing, leading and successfully completing the Medicare Bid filing process. experience pricing benefits and contracts. Requires an understanding of the tools needed to calculate these values. experience calculating IBNR Reserve estimates with the knowledge to direct the development of the entire process. Certificates, Licenses, Registrations: Must be either a Fellow or associate of the Society of actuaries as well as a Member of the american academy of actuaries. Must have sign-off authority for Medicare bids.

sales representatiVe (Pleasanton, CA)

The primary objective of the Sales Representative is to identify prospective Medicare-eligible members, explain the features and benefits of the avail-able products in that marketplace and enroll the prospects into a product that best fits their needs. Successful candidates generate leads from a variety of sources including networking, physician and pharmacy referrals, grassroots sources as well as from member referrals. Education and/or

Experience: Bachelor’s or associate’s degree preferred, high school diplo-ma or equivalent required. prefer 1-2 years of experience selling Medicare advantage products or relevant sales experience with a track record of success. Certificates, Licenses, Registrations: Must maintain a current, active Life and Disability agent license for the state in which the represen-tative enrolls prospects. ability to travel within assigned region. The suc-cessful candidate must have reliable means of transportation. Candidate must have strong leadership skills.

regional perforMance Manager (San Bernardino, CA / San Jose, CA)

The Regional performance Manager is responsible for negotiating, imple-menting and managing capitated and fee-for-service agreements with individually contracted pCps, medical groups, specialists and urgent care centers in an assigned region. position requires a strong understanding of reimbursement methodologies, contract language, negotiation strategies, financial modeling and analysis, managed care and Medicare advantage plans. This individual will analyze cost / revenue trends to develop, imple-ment and monitor corrective action plans in partnership with internal and external clients. In addition, will develop new and existing provider net-works as necessary. Education and/or Experience: Bachelor’s degree or equivalent experience. Minimum of 5 years managed care contracting/net-work development experience. Certificates, Licenses, Registrations: none required. ability to travel within assigned region. The successful candidate must have reliable means of transportation. Candidate must have strong leadership skills.

To submit your CV/Resume for consideration: Visit http://www.caremore.com/en/About/Careers.aspx to apply online.For more information about CareMore please visit www.caremore.com

Community Hospital Foundation, based out of Monterey, Ca, is seeking a

director of health plan deVelopMent

This is a great opportunity for an individual to direct and manage all functions related to the requirements to obtain and operate a Knox Keene license. Leads and manages the project to create the infrastructure to successfully comply with all legal, regulatory, operational, financial, and con-tractual requirements for such license. also responsible for leading the process to form a Medicare advantage Health plan. Requirements include previous experience in running or managing organizations holding Knox Keene licenses. Must have health plan background and understand the organiza-tional, financial, legal, operational, contractual, regulatory, and management requirements. Bachelors degree required; Masters degree preferred; MHa or MBa is a significant advantage. Must have Managed Care experience working with the Department of Managed Health Care or Knox Keene license holders. proficient in computer and social media tools.

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MANAGER, SERVICE LINE STRATEGY (Los Angeles)

Will prepare and manage the following types of projects: medical practice assessments, medical group performance improvement initiatives, care model redesign, including medi-cal home implementation, medical group interim management, and physician-hospital alignment strategy (e.g., aCO, clinical integration, bundle payment). The successful candidate will have a high degree of direct client interaction, be responsible for managing projects, ability to apply lean principles, par-ticipate in the business development and sale of consulting projects, and use their time in a billed-hours environment. Masters degree in Business or related field preferred, 5 years of medical practice management experience and a minimum of 2 years of consulting experience required.

VP, CLINICAL SERVICES (Anywhere in the U.S.)

The Camden group is seeking a strong candidate to lead the following types of engagements: clinical integration, aCO readiness and implementation, and hospitalist/care manage-ment improvement throughout the U.S. The candidate will join a highly skilled team of clinicians and managers to develop state of-the-art delivery networks. Will present to and collaborate with the executive teams of hospitals, physician groups, health systems, and provider-owned health plans. The candidate will have a high degree of proven clinical, systems, managed care, interpersonal, leadership, and writing and presentation skills. a person with experience in a consulting environment preferred. RN or M.D.; 10 years of healthcare experience required.

MANAGER, FINANCE (Boston, MA)

Responsibilities include managing consulting engagements and teams; interfacing with clients at senior management and board levels, and some business development. The company’s

client base consists of healthcare systems and hospitals, phy-sician groups, insurance/managed care organizations and other healthcare service/product/technology companies. The successful candidate will have excellent analytical and com-munication skills. This experience should include areas such as: financial modeling, feasibility studies, business and strate-gic planning and mergers/acquisition analysis. requirements: Masters degree, 4+ years of healthcare industry experience in managed care, hospital/medical group finance; and/or experi-ence with a national healthcare consulting firm, leadership and team player capabilities, and excellent organizational, analyti-cal, and written and oral communications skills.

MANAGER, CLINICAL SERVICES (Rochester, NY)

The Camden group is seeking a strong candidate to lead the following types of engagements: clinical integration, aCO readi-ness and implementation, and hospitalist/care management improvement throughout the U.S. The candidate will join a highly skilled team of clinicians and managers to develop state of-the-art delivery networks. Will present to and collaborate with the executive teams of hospitals, physician groups, health systems, and provider-owned health plans. The candidate will have a high degree of proven clinical, systems, managed care, interpersonal, leadership, and writing and presentation skills. a person with experience in a consulting environment preferred. RN or M.D.; 5+ years of healthcare experience required.

Our positions require proficiency with Microsoft Office Software, the ability to work well with individuals at all levels of an organi-zation, and excellent analytical, written, and oral communications skills. Comprehensive compensation packages offered.

The Camden Group has been providing business advisory and management services to the healthcare industry exclusively since 1970. We have served more than 1,000 clients nationwide. Due to our growth the following opportunities are available:

contact information: Susan esther | The Camden group

[email protected] | www.TheCamdengroup.com

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MEDICAL DIRECTOR

excellent opportunity for an experienced Medical Director with a strong UM and managed care back-ground who can lead all aspects of clinical operations. The ideal candidate will have demonstrated successful implementation of process improvement; the ability to oversee patient care through Hospitalist and case management programs; the ability to manage eR utilization; and the knowledge and ability to manage global risk. We require superior interpersonal and con-flict resolution skills with the ability to articulate the goals and objectives of the organization throughout the provider network; an understanding of financial systems, business strategies, and the development of an integrated healthcare delivery network founded in quality with a commitment towards service and excel-lence. Candidate should be a board certified physician with at least 5 years clinical practice experience along with 5 years experience in a managed care clinical position and documented leadership capabilities.

This position offers a competitive salary and incentive package.

RISK ADJUSTMENT CODER

Will assist with all HCC projects. Responsibilities include handling risk adjustment related activities to ensure that CMS coding and documentation guide-lines are met and members risk scores are accurately reflected. This position will assist in developing strat-egies to improve risk score performance through col-laborations with health plans and providers. In addi-tion handle chart reviews to identify coding oppor-tunities, lead training seminars, physician education, perform internal chart audits to ensure preparedness for potential RaDV audits, and other projects as assigned. The position requires 3+ years of healthcare coding experience, understanding of managed care, strong knowledge of CMS risk adjustment guidelines, CpC license or equivalent, strong communication skills with the ability to perform group presentations, strong data analysis, computer proficiency, and valid Ca driver’s license.

Qualified candidates should send their resumes per Title in confidence to: [email protected]

HEALTHLEADERS INC. KAI010911B

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KAI90437

Healthcare

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health is our businessMake it yours. At Kaiser Permanente, we realizethat it takes more than expert medical care to beone of the nation’s leading health care providersand not-for-profit health plans. It takes advancedtechnologies, state-of-art facilities, and the peopleto support them. Come impact your future, and thefuture of care. If this sounds like something youbelieve in, consider joining us in Pasadena, California.

DIALYSIS SR. MANAGER OUTSIDE MEDICAL CONTRACTSIn this role, you will supervise contract managers, as wellsas develop new contracting strategies and negotiatecontracts for the delivery of institutional healthcare tohealth plan members. You will have direct accountability todevelop and maintain competitive provider agreementsand work in collaboration with Region and Service Arealeadership to develop and implement market and serviceline strategies affecting the contractual relationships withoutside providers for facility-based and/or ancillaryservices. In addition you will manage this process in anenvironment of varying interests and expectations bycreating opportunities to align the contracting interests of the region and specific service areas.

Your qualifications should include a bachelor’s degree,although a master’s degree/MPH/MSHA/MBA is preferred.You should have played a significant, progressivelyresponsible role in a network contracting for health servicefor an integrated system or managed care organization.Previous experience working with various reimbursementmethodologies, financial analysis, and decision supportsystems is important and managerial/supervisory experiencewould be helpful. You should have demonstrated skills inthe identification and resolution of business problems withina team setting and possess an excellent understanding ofthe health care industry, provider community, competitivemarket strategies, and health and hospital system operations.You must also have a history of success in maintainingstrong customer focus and achieving high levels ofcustomer satisfaction, along with the ability to work in ateam environment with a variety of internal and externalpersonnel at various levels of responsibility. Strong verbaland written communication, project management,leadership, negotiation, and facilitation skills are necessary,as is the ability to work in a Labor ManagementPartnership environment.

We offer competitive compensation and benefits. Forimmediate consideration. please e-mail your resume [email protected] or visit jobs.kp.org for completequalifications and job submission details, referencing jobnumber 146070. Principals only.

jobs.kp.org

KAISER PERMANENTE IS PROUD TO BE AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER.

http://kaiserpermanentejobs.org

mailto:Jolanta.U.Buschini%40kp.org?subject=

http://kaiserpermanentejobs.org





state Medicaid content expert (independent contract)

HCpro is looking to recruit state content experts to contribute to a new Revenue Cycle Intelligence Solution. We are looking for thought-leaders in the following states: California, Florida, Texas, New York, Massachusetts, New Jersey, in addition to other states. State content experts will be respon-sible for responding to questions that come in from our customers related to Medicaid rules and regula-tions, as well as state laws. experts also have the opportunity to write regular analysis articles related to Medicaid, Medicare, and state laws. The ideal candidates would have been published in association magazines and newsletters. Job functions include: answer questions from customers regarding state Medicaid regulations and state laws. Write regular articles pertaining to state Medicaid regulations and state laws. Review articles written by other state experts.

Qualifications: Understanding of state Medicaid regulations and state laws. Strong writing skills. experience writing articles for newsletters and magazines. Involvement in various federal and state associations (e.g., aHLa, HCCa, aHIMa). advanced professional credentials (e.g., RHIa, RHIT, CHC, JD). Bachelor’s Degree (4 year college or university); Law degree a plus. 5-10 years related experience.

Computer Skills: Microsoft (Word, Outlook, power point).

please use this link to apply: https://www5.ultirecruit.com/HCp1000/jobboard/

NewCandidateext.aspx?__JobID=354

HCpro is an equal opportunity/ affirmative action employer;

M/F/D/V are especially encouraged to apply.

Sponsor an Issue of California Healthfax

package includes:

for information,

please contact Bill clattenburg

at 888-834-4678,

or [email protected]

page 1 of 5September 11, 2006

CUSTOMER SERVICE CEnTER E-mail Subscribers: If you do not receive your copy of HealthFax, send

a request to: [email protected]. For renewals or other subscription questions, please call: 800/753-0131. By fax: 866/592-7573. By e-mail: [email protected].

published every Monday, California Healthfax is copyrighted by HCpro, 100 Hoods Lane, Marblehead, Ma 01945, and is transmitted sole-ly to the subscriber. any unauthorized copying, duplication or transmission is strictly prohibited. annual subscriptions are $159. For group and bulk subscriptions, call 800/753-0131.

EDITORIAL SUBMISSIOnSTo submit an item for consideration, con-tact John Leighty, editor. By e-mail:

[email protected]. By phone: 415/259-4848. For other questions, contact Bob Wertz, Managing editor. By phone: 800/639-7477, ext. 3456. By e-mail: [email protected]

December 31, 2009 | VoLuMe 16 | NuMBer 46

ADVERTISIng OppORTUnITIESTo advertise in California Healthfax, please contact Bill Clattenburg. By

e-mail: [email protected]. By fax: 800/698-2082. By phone: 888/834-4678.

2009: The Year in ReviewThis is placeholder copy for the 2009: The Year in Review to be distributed on

Thursday, December 31. While health reform faltered in the receding economy, there were bright spots in disease management, health IT, patient safety, and access to care for the poor, elderly, and uninsured. The fiscal crisis stalled passage of a new $141 billion budget for 81 days, draining state coffers as lawmakers managed to eliminate a $15.2 billion deficit only to face a new shortfall estimated at $14.2 billion by mid-2009. State regulators cracked down on HMos for rescinding policies of members after they sought medical care and banned the provider practice of balance billing where patients are charged for disputed sums. a state pay-for-performance initiative raised the bar on quality of care and awarded $65 million to high-achieving physician groups. as 2008 waned, fiscal pressures halted some hospital expansion and seismic upgrade projects, caused cuts in county health programs, and pushed the number of uninsured to 6.3 million. Foundations helped fill gaps, awarding more than $100 mil-lion to support clinics for the poor and disadvantaged and to advance technologies and workplace safety. The California Endowment gave $7.5 million to help keep Healthy Kids afloat in 32 counties while First 5 California donated $16.8 million so Healthy Families California can enroll children through June of ‘09, and the fiscally pinched state is stalling on paying $8 billion to a prison overseer to rebuild dilapidated hospitals and clinics for inmates, setting the stage for a funding battle in U.S. District Court. I hope you enjoy this peek at the Year In Review, and I’m atop the lookout perch of California Healthfax to report on the achievements, challenges, and changing dynamics of California’s $1 trillion healthcare industry in what is shaping up to be a politically supercharged 2009. — John Leighty, editor, CaLifornia heaLthfax

WE MAKE MANAGED CARE WORK! BETTER CONTRACTS! BETTER TERMS!

www.AthenaGroup1.com

Toll free: 888-8-ATHENA

e-mail: [email protected]

We work with several IPAs & Hospitals and can assist with all your Managed Care needs.

Looking to outsource your Managed Care Department or Contracting functions? We work with your Team. We can provide Interim and Outsourced Contracting Management.

Call or e-mail us today for a free consultation.

• HealthPlan Contracting Negotiations • IPA and HealthPlan Network Expansions• Review your HealthPlan Templates • Medicare Advantage Network Contracting• Need assistance on Contract renewals? • Practice Management

This special year end issue of California Healthfax

is sponsored by Monarch Healthcare, please see

their ad on page 6 for valuable career opportunities

with this premier organization.• • • • • • • • • • • • • • • • • • • • • • • • • • • • • •




page 6 of 13December 31, 2009

Monarch HealthCare is a medical group (“Ipa”) of over 2500 independent physicians in private practice dedicated to prac-ticing medicine the way it was meant to be. Monarch HealthCare is owned and operated by doctors who believe in working collaboratively with all stakeholders to improve the delivery of healthcare in the communities we serve. We are an industry leader in providing coordinated care! Our commitment to our employees and our employee dedication to our physicians and patients is what differentiates us.

Monarch HealthCare is currently searching for exceptional candidates for these available career opportunities:

experienced Medical director, outpatient services: In this high profile position you will be tasked with the following: interacts with physicians, health plan staff, associated Medical Directors, and health plan mem-bers when a physician’s input is needed or required. The Medical Director, Outpatient Services is responsible for the Medical Management Function, which includes Referral Management, Case Management and Disease Management programs, as regulatory agencies require and the Ipa’s plan contracts stipulate.

In this collaborative role, you will partner with the Senior Medical Director along with the Vp of Clinical Services in order to create a leadership model that joins our physicians with our business leaders to exemplify Monarch’s quality and performance standards.

Our Medical Director, Outpatient Services will work in con-cert with various levels of management to successfully perform as a consultative arm to our Clinical Services and Case Management Departments, Utilization Management Committee, Member Services, Finance and provide policy planning and development.

Our ideal candidate for this exceptional career opportu-nity will be a graduate from a national accredited School of Medicine or Osteopathy; a doctoral degree (MD or DO); greater than 5 years related experience and/or training; or equivalent combination of education and experience including 3 years of clinical practice in direct patient care; and at least 3 years medical management experience in a managed care setting. In addition, the successful candi-date will possess sufficient clinical knowledge to interact with the physician members of the Ipa in all major medical specialties. Candidate must hold a valid, unrestricted license to practice medicine in the State of California along with board certification in their chosen specialty and a strong desire to work in tandem with Clinical Leadership to design, develop and execute special programs including correc-tive action plans. Candidates with a proven track record of quality leadership and exceptional teamwork in order to build and foster stellar working relationships in both Clinical and Operational departments are strongly desired.

electronic HealtH records iMpleMentation specialist: Responsibilities for this highly dynamic role include the implementation, configuration, training, and re-engineering of practice operations to support the successful adoption of an electronic practice management and electronic medical records software. Must be able to work in partnership with team members, physicians and their staff to design, configure, test, train, implement and support the use of the eHR software. Qualifications for this exciting opportunity include: prior experience implementing and train-ing an electronic health records system in a physician office setting or hospital setting. Strong ability to work as a collab-orative member of a team. Demonstrate ability to grasp new technologies. 3–5 years experience in a similar role preferred.

revenue recovery analyst—Hospital claiMs: Responsibilities for this detail oriented position include the review and analysis for risk pool medical payments. additional responsibilities will include timely reconciliation of capitation deductions, submission of stop loss recoveries to carriers and audit of payments received to ensure maximum recoveries and cost savings. Qualifications for this detail driven position include: 3 to 4 years related experience or 4 to 5 years prior experience in a medical claims processing or auditing environment. prior experience in a managed care setting preferred.

Monarch HealthCare has assembled a competitive compen-sation package that recognizes the many contributions by our dedicated employees and strives to keep our employees as satisfied, long term business partners! Our competitive salary, robust employee health plans, generous retirement package and “work-life balance” vacation schedules are the cornerstone of our employee friendly health and wel-fare plans! To join the best Ipa in Orange County, send a current resume to [email protected], where great careers begin! For more information on these positions and all of our available career opportunities, please visit our website at www.monarchhealthcare.com.

Monarch HealthCare would like to wish a Happy Holiday Season and all the best in the New Year

to our employees, partners and members!

• Banner featuring your logo on the cover of the issue

• A full page, first page ad in the featured display ads

https://www5.ultirecruit.com/HCP1000/jobboard/NewCandidateExt.aspx?__JobID=354

https://www5.ultirecruit.com/HCP1000/jobboard/NewCandidateExt.aspx?__JobID=354



e M p l o y M e n t o p p o r t u n i t i e s


MSO DIRECTOR

MSO located in San gabriel Valley is filling a Director of Operations position. The MSO manages over 120K lives. education and/or experience Requirements: 3-5 years related managed care experience, working knowledge of eZ Cap, Claims processing, eligibility, IT, Finance, and Compliance. To apply, send resume to Kendra at [email protected].

Sutter Health, Northern California’s largest nonprofit network of hospitals, physician groups, and health care services, is seeking candidates for:

The DIRECTOR, MANAGED CARE provides expertise and leadership in the development/implementation of managed care policy and strategy. position implements institutional and physician managed care strategies, coordinates commu-nications and ensures implementation of negotiated contracts. applicants should possess the ability to lead or participate in a disciplined team approach in negotiations with payers on behalf of all Sutter affiliates, and extensive knowledge of the managed care environment, negotiation process and contract-ing principles. Master’s degree in Healthcare, Business or related field is preferred. position requires understanding of the California health care market, plans, managed care deliv-ery and/or alternative financing systems, knowledge of fed-eral/state regulations, financial principles, capitation account-ing and data systems, and the working relationships between health plans, physicians and institutional providers.

The CONTRACT MANAGER, MANAGED CARE partici-pates in negotiations for payer agreements for hospital, professional and ancillary providers. Supports negotia-tions, implementation of managed care contract compli-ance, assures contract performance success, works through disputes. applicants should possess a minimum of 5 years experience negotiating/implementing managed care con-tracts for hospitals, medical groups and/or HMOs, experi-ence with contract language, supervisory experience, and knowledge of market trends for providers. Bachelor’s degree in Healthcare, Business or related field is required and knowledge of operational implications of managed care contracts relative to both medical groups/Ipas and facili-ties and understanding of regulatory requirements for con-tracting in relation to Knox-Keene, Department of Managed Health Care, CMS, HIppa or eRISa.

To apply, visit the employment section at www.sutterhealth.org, and apply to job numbers SHSS-1201426 or SHSS-1204902.

Health plan in Ventura County is seeking qualified applicants for the following positions:

• chief operations officer

• director, health serVices

• Manager care coordination

• director of it

• hr director/Manager

• hr analyst ii

• hr technician

Competitive Salary and excellent Benefits package.

please see: www.calopps.org/member.cfm and click on Local/Regional government Services for complete job description. Only applications/resumes submitted on CalOpps will be accepted.

Medical claiMs exaMiner – part time

adventist Health is seeking a part Time Claims examiner locat-ed in its Ontario, Ca office. Candidate will provide claims pay-ment and other related activities for services provided to pre-paid (capitated) managed care members on behalf of adventist Health hospitals and will work closely with the Managed Care Department, as well as other departments. Candidate will also interact with health plans and other outside entities. The position requires an individual who is highly organized and able to handle multiple tasks. Must have analytical and problem solving skills, be detail oriented and have excellent written and oral communication skills. Successful candidate must have a minimum of 3 years experience in performing claims payment activities. Knowledge of eZ Cap is preferred.

Qualified candidates may email their resume to [email protected], or mail it to:

adventist Health, attn: personnel 3602 Inland empire Blvd., Suite C-110

Ontario, Ca 91764



e M p l o y M e n t o p p o r t u n i t i e s


Molina Healthcare is seeking a hedis prograM Manager (Contractor/Temp)

in Long Beach, Ca.

Responsible for documentation of the HeDIS work plan and timeline for 2013 HeDIS, overseeing the HeDIS staff assign-ments, tracking the progress and making adjustments to the timing and scope of the assignments, monitoring of data feeds from Ipas and provider offices and entry into the HeDIS data repository, monitor staff progress in using access and SQL training for work efficiencies. Must have a Bachelor’s degree in Computer Sciences, Nursing, Business or Healthcare administration, 6-8 years HeDIS experience accepted in lieu of education. Minimum 2 years HeDIS managed care experi-ence and basic knowledge of NCQa and Quality Improvement.

To apply, go to: www.molinahealthcare.com

director of Medical ManageMent (r.n.)

easy Choice Health plan HMO, one of California’s fastest grow-ing Medicare advantage plans, is recruiting for the position of director of Medical Management (r.n.). Successful candi-dates will possess a current California R.N. license and be well versed and experienced in managed care medical and quality management including Medicare advantage, HeDIS, and Care Management. The position supervises several other clinical and managerial positions and works closely with the plan’s Medical Director. Interested and qualified candidates can submit resume and salary history/requirements to [email protected], or fax to 949-999-3848.

http://tbe.taleo.net/NA5/ats/careers/requisition.jsp?org=MOLINAHEALTHCARE&cws=4&rid=5389

Documents

top StoriES State Lawmakers Crafting plan for …promos.hcpro.com/pdf/CA_HF_081312.pdfseeks Chapter 9 bankruptcy pro-tection from creditors. A group of retirees filed a motion to block