LSMA Management Inc

Role Description The Institutional Claims Examiner is responsible for the accurate, timely, and compliant adjudication of institutional (hospital/facility) medical claims in accordance with applicable HMO, Medi-Cal, Medicare, and Commercial contracts. This role ensures proper determination of financial responsibility among health plans, providers, and delegated entities, while adhering to California and federal regulatory requirements applicable to a healthcare Management Services Organization (MSO). Qualifications - Minimum: High School Diploma or equivalent. - Preferred: Additional coursework or training in healthcare administration, medical billing, or managed care. Requirements - Minimum: Five years of managed care claims processing experience. - Preferred: Two – three years of recent institutional/hospital claims experience involving Medicare, Medi-Cal, HMO, PPO, and Commercial products. - Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position. - Professional claims or medical billing certifications preferred. - Advanced knowledge of institutional claims processing, including UB-04 and CMS-1500 claim forms. - Strong understanding of DRG, OPPS/APC, Ambulatory Surgery, and RBRVS reimbursement methodologies. - Working knowledge of Medi-Cal, Medicare, and California managed care regulations, including prompt payment requirements. - Proficiency with claims processing systems, third-party pricing software, and standard office applications (Microsoft Office). - Strong analytical, problem-solving, and decision-making abilities. - Excellent written and verbal communication skills; ability to read, write, and communicate effectively in English. - Ability to manage multiple priorities in a fast-paced, deadline-driven environment. - Demonstrated attention to detail and commitment to accuracy and compliance. Benefits - Light physical activity, including the ability to lift up to 10 pounds and to bend, stoop, reach, and file materials as needed. - Ability to frequently use a computer, keyboard, and standard office equipment. - Maintain focus, manage workload pressures, and meet deadlines in a professional healthcare office or remote work environment. Pay Range $31.00 - $36.00 / hourly

Role Description The Risk Adjustment Specialist – Coding Compliance supports the organization’s delegated Risk Adjustment and Coding Compliance programs by performing specialized audit support, documentation review coordination, coding validation support, medical record analysis, and compliance activities to promote accurate and complete Hierarchical Condition Category (HCC) capture in accordance with Centers for Medicare & Medicaid Services (CMS), California Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA), Office of Inspector General (OIG), and contracted health plan requirements. - Supports coding compliance oversight activities related to Medicare Advantage Risk Adjustment, Risk Adjustment Data Validation (RADV), provider documentation integrity, and coding accuracy initiatives. - Assists with identifying documentation gaps, monitoring coding compliance trends, coordinating audit preparation activities, and supporting provider education efforts to ensure accurate Risk Adjustment Factor (RAF) scoring and regulatory compliance. - Collaborates closely with Coding Compliance leadership, certified coders, providers, population health teams, utilization management, care management, quality improvement, and health plans to support compliant documentation and coding practices, audit readiness, and delegated risk adjustment program performance. Qualifications - Minimum: High school diploma or GED equivalent required. - Preferred: Associate’s degree or higher in healthcare administration, public health, social services, or related field. - Minimum: At least one year of experience in one or more of the following areas: risk adjustment, coding compliance, medical record review, managed care, healthcare administration, managed care or MSO environment, medical office or provider operations. - Preferred: Experience supporting Medicare Advantage Risk Adjustment programs. Experience supporting CMS RADV audits or coding compliance audits. Experience in an MSO, IPA, health plan, delegated entity, or managed care environment. Experience working with electronic health records, coding software, or Risk Adjustment platforms. - Certification(s): Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or other coding certification preferred. - Knowledge of CMS Risk Adjustment methodology, HCC documentation requirements, and RAF score principles. - Understanding of Medicare Advantage Risk Adjustment, coding compliance, and documentation integrity requirements. - Familiarity with CMS RADV audit standards, DMHC regulatory requirements, NCQA standards, and delegated health plan oversight requirements. - Ability to identify documentation deficiencies, coding inconsistencies, compliance risks, and audit-related concerns. - Strong organizational, analytical, auditing, and data tracking skills with exceptional attention to detail and accuracy. - Ability to maintain accurate records, audit logs, compliance documentation, and reporting tools. - Proficiency with electronic health records, Risk Adjustment platforms, coding software, and Microsoft Office applications. - Strong verbal and written communication skills with the ability to communicate professionally with providers, coders, leadership, health plans, and interdisciplinary teams. - Ability to handle confidential and sensitive information in compliance with HIPAA and organizational policies. - Ability to manage multiple priorities, deadlines, and audit-related activities in a fast-paced managed care environment. - Ability to work independently while collaborating effectively within interdisciplinary operational and compliance teams. Requirements - The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. - Primarily sedentary work involving prolonged computer use. - Occasional standing, walking, and local travel may be required. - Ability to lift up to 20 pounds occasionally. - Requires strong attention to detail, data analysis capability, and effective communication skills. - Work is performed in an office or remote environment supporting electronic medical record and Risk Adjustment systems.

Description JOB SUMMARY The California Children Services (CCS) Coordinator is responsible for coordinating and supporting medically necessary services for children eligible under the California Children Service program. This position works collaboratively with CCS Case Managers, healthcare providers, families, and community partners to ensure timely, compliant, and effective delivery of services in accordance with State, DHCS, and CCS program requirements. Requirements MINIMUM & PREFERRED QUALIFICATIONS Education/Training Minimum: High school diploma or equivalent Preferred: College coursework in healthcare, social services, or related field Experience Minimum: 2+ years of experience in a managed care, IPA, MSO, or healthcare environment Preferred: Experience working with California Children Services (CCS) Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position. Skills, Knowledge & Abilities · Knowledge of medical terminology and coding systems including CPT, HCPCS, ICD-9/10, and RVS · Proficiency with Microsoft Office (Word, Excel, Outlook, Teams), Zoom, and Adobe · Strong organizational and time-management skills with the ability to multitask · Strong written and verbal communication skills · Ability to work independently in a fast-paced, highly confidential environment · Strong problem-solving and critical-thinking skills · Bilingual English/Spanish preferred PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This role requires prolonged periods of sitting, frequent computer use, telephone communication, and the ability to manage multiple priorities while maintaining attention to detail. Work may be performed in a remote or office-based environment.

Description JOB SUMMARY The Manager of Utilization Management (UM) is responsible for overseeing and directing the organization’s utilization management program to ensure appropriate use of healthcare services, regulatory compliance, and high-quality patient care outcomes. Under the direction of senior leadership, the UM Manager supervises daily UM operations, including prospective, concurrent, and retrospective review activities, while ensuring adherence to CMS, DMHC, and health plan requirements. This role provides leadership to UM staff, supports clinical decision-making processes, ensures timely authorization determinations, and promotes efficient healthcare resource utilization through effective team management, process improvement, and cross-functional collaboration. Requirements MINIMUM & PREFERRED QUALIFICATIONS Education/Training Minimum: Associate’s degree or completion of Vocational Nursing Program. Preferred: Bachelor’s Degree in Nursing, Healthcare Administration, or related field. Experience Minimum: At least five years of experience in utilization management, case management, or managed care and at least one year of leadership or supervisory experience. Preferred: Clinical nursing experience. Experience in a health plan, MSO, IPA, or managed care environment. Experience with Medicare Advantage and Medi-Cal populations. Experience with InterQual, MCG, or similar criteria. Familiarity with EZ-Cap, EZ-Net, DocStar, or similar systems. Knowledge of ICD-10, CPT, and HCPCS coding. Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position. Certification(s) Current California Licensed Vocational Nurse (LVN) license in good standing and Basic Life Support (BLS) certification preferred Skills, Knowledge & Abilities · Strong knowledge of utilization management principles and medical necessity criteria · In-depth understanding of CMS, DMHC, and health plan regulations · Leadership, coaching, and team development skills · Strong analytical, problem-solving, and decision-making abilities · Ability to manage multiple priorities in a fast-paced environment · Excellent written and verbal communication skills · Proficiency with EMR systems and UM platforms · Strong organizational and time management skills PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or remote environment and involves prolonged sitting while reviewing medical records and documentation. The position requires frequent use of a computer, telephone, and electronic medical record systems. Occasional standing, walking, and light lifting of materials up to approximately 20 pounds may be required. The role requires the ability to review detailed clinical information, maintain concentration for extended periods, manage multiple priorities in a fast-paced environment, and communicate effectively with providers, staff, and external partners.

Description JOB SUMMARY The Internal Audit Management LVN supports the oversight and monitoring of delegated functions of contracted medical groups to ensure regulatory, accreditation, and health plan compliance. This role assists with audit preparation, internal reviews, corrective action follow-up, reporting governance, letter accuracy, and process standardization. The LVN collaborates with Medical Management leadership, IT, analytics, and external partners to help maintain compliant, timely, and accurate operational performance. Requirements MINIMUM & PREFERRED QUALIFICATIONS Education/Training Minimum: Graduate of an accredited Licensed Vocational Nurse program. Preferred: Coursework or training in quality management, managed care, compliance, or healthcare administration. Experience Minimum: 10+ years of experience in Delegation Oversight, Medical Management, Utilization Management, Quality Management, or related healthcare operations. Prior supervisory or leadership experience. Preferred: Experience with HEDIS or quality performance measures. Experience in system testing, change control, or IT partnership environments. Advanced experience in reporting tools (SQL/BI), Excel, or healthcare analytics. Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position. Certification(s) Current State LVN License Preferred: Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM), and/or Project Management Certification (CAPM/PMP). Skills, Knowledge & Abilities · Knowledge of delegated functions, compliance standards, and health plan reporting requirements. · Strong attention to detail and accuracy in documentation and letter review. · Ability to interpret guidelines and apply them within LVN scope to operational processes. · Proficiency in medical terminology, documentation standards, and regulatory timeframes. · Strong communication, teamwork, and stakeholder support skills. · Ability to coordinate tasks and support staff without independent clinical decision-making authority. · Competence in Microsoft Excel, reporting tools, and electronic workflows. PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position involves prolonged computer-based work requiring frequent use of a keyboard and mouse, along with regular walking, standing, bending, and the ability to lift or move up to 25 pounds. It occasionally requires stooping, kneeling, crouching, or crawling. The role demands strong visual capability—including close, distance, color, peripheral vision, depth perception, and focus adjustment—and the ability to concentrate for extended periods while managing interruptions and meeting deadlines. Work is primarily remote but may involve travel for meetings or oversight activities.