Professional Documents
Culture Documents
California Edition
Calendar
December 1
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E-Mail info@payersandproviders.com with the details of your event, or call (877) 248-2360, ext. 3. It will be published in the Calendar section, space permitting.
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NEWS
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Advertise Here
(877) 248-2360, ext. 2
In Brief
Primes Billing For Heart Failure Examined
Chino Valley Hospital has allegedly been billing Medicare to treat patients for heart failure at rates far higher than the national average, according to a recent report by California Watch. According to analysis of billing data for Chino Valley, nearly onethird of its Medicare patients in recent years suffered from acute heart failure--a rate nearly six times the average for California. The facility is owned by Ontario-based Prime Healthcare Services. California Watch, a non-prot investigative journalism organization, noted the hospital billed Medicare for virtually no heart failure patients in 2006, just prior to Medicare initiating a rule change that allowed a bonus for treating such cases. Between 2008 and 2010, the hospital treated nearly 2,000 patients for the ailment. Eighteight percent of the time, the diagnoses was billed in a way that would trigger the extra payments. Prime ofcials disputed the report by California Watch, which has been scrutinizing Prime's billing practices. Anthony Glassman, a Prime attorney, told the organization its analysis was "faulty, unfair and biased." He added that Chino Valley treated such a large number of heart failure patients because many are admitted from nearby nursing homes and through the hospital's emergency department.
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http://www.healthwebsummit.com/ppcalifornia121511.htm
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Continued on Page 3
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NEWS
CHA (Continued from Page One)
California provided compelling evidence about the impact these cuts will have on access to care for our most vulnerable patients, said CHA President C. Duane Dauner. We believe that the cuts are in violation of federal Medicaid law and without regard for the welfare of thousands of patients with complex medical needs. The CHA, which led suit against the state and federal government last month, wants to block rate cuts for skilled nursing
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Advertise Here
(877) 248-2360, ext. 2
*For our ads, not your hospital
In Brief
Blue Shield announced the credits earlier this year as part of a pledge to limit its net income to 2% of its annual revenue. Blue Shield is a not-for-prot organization. As a mission-based, not-forprot health plan, we made this commitment to help keep coverage affordable for our members. While these credits will help our customers, every player in the healthcare industry must do more to reduce the cost of care, said Blue Shield Chief Executive Ofcer Bruce Bodaken. The average credit for an individual plan enrollee is $135, with a family of four receiving about $420. Large and mid-sized group customers will receive credits ranging from $195 to $235 per enrollee, with small groups receiving an average of $220.
facilities operating within hospitals. According to a recent survey of its membership, half would close their skilled nursing facilities, while more than a third are pondering reducing beds or closing such services to Medi-Cal enrollees. In addition to the CHA suit, the California Medical Association, California Dental Association, California Pharmacists Association and the National Association of Chain Drug Stores sued late last month.
PAYERS & PROVIDERS reaches 5,000 hospital, health plan and nonprot executives statewide. There is no better venue for marketing your organization or conference, or recruiting new staff.
OPINION
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MARKETPLACE/EMPLOYMENT
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MARKETPLACE/EMPLOYMENT
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CLINICAL PHARMACIST (Long Beach, CA) JOB SUMMARY: Work in collaboration with the pharmacy staff to update and maintain the formulary used by SCAN. Spearhead and oversee the implementation of key clinical pharmacy programs. Work with appropriate departments to produce pharmacy related marketing materials in accordance with CMS guidelines. ESSENTIAL JOB RESULTS: Produce marketing materials within internally determined timeframes with accuracy and in accordance with the CMS marketing guidelines. Utilize CMS model templates to populate pharmacy specific information per CMS guidelines; partner with Marketing, Compliance and Member Education as needed. Work in collaboration with other pharmacy staff to support the annual formulary/ prior authorization (PA) criteria submission to CMS. Prepare monographs & prior authorization/ non-formulary exception criteria and present clinical data on new drug therapies and clinical programs at Pharmacy and Therapeutics Committee meetings. Review new drugs with the Pharmacy & Therapeutics Committee within 90-180 days of being marketed. Decisions related to the drug formulary and utilization management restrictions will reflect compliance with CMS guidelines. Develop and update Prior authorization criteria by using appropriate clinical references when new clinical information becomes available. Coordinate the implementation of new and revised PA/non-formulary exception criteria with the PBM company. Develop and/or implement clinical pharmacy programs in-house or in collaboration with the Pharmacy Benefit Management (PBM) company as needed. Daily interactions with SCAN employees and/or PBM representatives may be required. In-depth knowledge of CMS guidelines related to the Clinical Pharmacists job and the ability to ensure compliance with the CMS requirements is essential. Maintain professional and technical knowledge by attending educational workshops; reviewing and contributing to professional publications; establishing personal networks; participating in professional societies. Contribute to team effort by accomplishing related results as needed. QUALIFICATIONS: Pharm.D. Degree with a residency program in Drug Information or Geriatric Pharmacy preferred. Pharmacy Licensure in California required. Part D experience preferred. Managed care experience at a PBM, health plan or medical group preferred. Excellent verbal and writing skills required. Proficient in MS Office. FT position, M-F 8 AM to 5 PM, occasional extended work hours as needed. Telecommute up to 25%. Apply to www.scanhealthplan.com - Job Opportunities - Req # 11-285
DIRECTOR, PHARMACY CLINICAL SERVICES (Long Beach, CA) JOB SUMMARY: Reporting to VP of Pharmacy Services, this position will play a central role in pharmacy management for a senior-focused Medicare Advantage Plan with over $140 million in annual drug expenditure. Director will be accountable for providing leadership support to department, managing change, improving efficiencies and managing and ensuring strong clinical programs aligned with organizational direction. In addition, Director will service as Part D pharmacy expert for the department and organization. ESSENTIAL JOB RESULTS: Serve as a clinical/subject matter expert on pharmacy benefit management. Coordinate the work product of clinical operation team members (clinical pharmacists and pharmacy benefits administrators). Oversee PBM operations to ensure high service level to SCAN and our members. Oversee clinical and technical initiatives (eg. MTM, e-prescribing, provider/member web based tools). Monitor, evaluate, develop and implement quality initiatives (i.e. DUR programs) and drug cost management strategies. Serve to oversee clinical operations of pharmacy department to ensure proper accuracy and efficiency. Serve as backup of clinical operations when necessary (Grievances, appeals, medication therapy management reviews, formulary management). Participate in business and budget planning process. Oversee pharmacy operations for Employer Group Retiree Plans. Lead department initiatives. Foster strong relations with internal departments and external providers. Serve as pharmacy expert on a variety of committees and workgroups. Maintain current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance. QUALIFICATIONS: California State Board of Pharmacy, Registered Pharmacy license required. Doctor of Pharmacy (Pharm. D.), with residency in clinical pharmacy practice preferred. Five (5) years or more of managed care pharmacy experience as a Director; or equivalent experience in a managed care setting, strongly preferred. Demonstrated knowledge of Medicare Part D required. Medicaid knowledge preferred. Excellent written, oral and interpersonal communication skills required. Strong computer skills using MS Word, Excel and PowerPoint required. Strong leadership & supervisory skills required. Strong analytical, problem-solving, negotiation, and decision-making skills required. FT position, M-F 8 AM to 5 PM, occasional extended work hours as needed. Apply to www.scanhealthplan.com - Job Opportunities Req # 11-375
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MARKETPLACE/EMPLOYMENT
Alameda Alliance for Health is a public, not-for-profit managed care health plan for lower income people in Alameda County. TheAlliance provides healthcare coverage to over 130,000children and adults through four programs: Medi-Cal, Healthy Families, Alliance Group Care, and Alliance CompleteCare.
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Health care you can count on. Service you can trust.
DIRECTOR, MEDICARE
This position is responsible for the oversight and management of the Medicare Special Needs Plan and will work cross-functionally within the organization and externally on all issues related to Medicare. The position will also provide leadership on Medicare staffing and functions, organizational structure, and operational standards. The position requires an individual with Medicare operations and oversight experience, preferably who also has experience with dual eligibles or Medi-Cal. A Masters degree in Business Administration, Public Health, Public Policy, or related field is preferred, plus 2 years experience and/or training. A minimum of 2 years of recent Medicare Advantage Part D plan experience is required.
DIRECTOR, COMPLIANCE
This position is responsible for developing, implementing, and providing oversight of all compliance activities related to the Alliances adherence to laws, regulations, and contracts that govern its business. The position will assess areas of risk, develop the annual audit plan and internal audit tools, conduct internal audits, and implement plans to reduce risk and maintain compliance. The position is also responsible for compliance training, and managing the intake, investigation/ reporting of fraud, waste and abuse incidents. A Bachelors degree is required and a minimum of 5 years compliance experience in a managed care plan or a community clinic is required. A Masters degree and certification in Healthcare Compliance (CHC) is preferred.
We offer an excellent compensation & benefits package. Please visit our website at www.alamedaalliance.org and click on the Careers button for more specific job information and to apply for these positions. EEO.
CAN HELP.
We publish advertisements for those seeking new career opportunities for just $1.25 a word. If you prefer discretion, well handle all responses to your ad. Call (877) 248-2360, ext. 2, or e-mail advertise@payersandproviders.com.
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MARKETPLACE/EMPLOYMENT
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PROJECT MANAGER-HEDIS (Long Beach, CA) JOB SUMMARY: Position supports the Quality Initiatives Team and Healthcare Informatics in activities related to quality improvement, measurement, reporting and analysis. ESSENTIAL JOB RESULTS: Manage all aspects of the HEDIS project, including, but not limited to, data collection, abstraction, and the compliance audit. Hire, train and supervise temporary HEDIS staff. Identify data sources and ensure accuracy and completeness of the HEDIS data repository. Collaborate with other departments on project implementation. Provide weekly status update to management. Conduct analyses to identify barriers, gaps, and opportunities for improvement. Educate network providers on evidence based clinical guidelines and best practices to improve quality of care and service for members through webinars, on-site meetings, mail and electronic correspondence. Conduct targeted member and provider outreach and education via electronic data exchange, phone calls/IVR, mailings, etc. Utilize HEDIS/HOS/CAHPS metrics to monitor and improve clinical outcomes. Maintain professional and technical knowledge by attending educational and technological workshops. QUALIFICATIONS: Bachelors or Masters degree in health care or related area with emphasis in quantitative data analysis. Experience in quality improvement and HEDIS project management. Moderate to strong knowledge in processing of claims, encounters, and pharmacy data. Proficient in SAS/SQL programming. Proficient in Microsoft Office applications. Strong verbal and written communication skills with the ability to express ideas in a clear and organized manner. Strong organizational and time management skills to efficiently handle multiple projects with changing priorities. FT position, M-F 8 AM to 5PM, with extended working hours and occasional travel as needed. Apply to www.scanhealthplan.com Job Opportunities Req. # 11-415
Competitive salary, plus excellent benefits. If you meet the requirements of this job opportunity, please send your resume to HR@goldchp.org. NO THIRD PARTY AGENCY OR SEARCH FIRMS.
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