Manager, Service Validation Unit

L.A. Care Health Plan•Los Angeles, CA

25d

About The Position

The Manager, Service Validation Unit (SVU) manages and leads L.A. Care’s pre-payment service validation function designed to strengthen program integrity and prevent improper payments before claims are released. This position oversees processes that independently verify the accuracy, authenticity, and appropriateness of billed services by conducting structured outreach to members, referring/rendering providers, and other stakeholders. The Manager ensures timely, accurate, and thorough completion of validation activities prior to adjudication, including verification of dates of service, service receipt, provider involvement, referral accuracy, and benefit/authorization alignment. This position ensures that SVU decisions support correct payment, reduce waste and rework, and strengthen the end-to-end claims ecosystem. The Manager partners closely with cross-functional key stakeholders to ensure findings lead to upstream improvements and preventive control enhancements. This position oversees a team responsible for outreach, documentation, triage, and evidence collection. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendations on the department's strategic planning and/or long-term decision-making.

Requirements

Bachelor's Degree
At least 5 years of experience in healthcare operations.
At least 3 years of leading, supervising/managing staff.
Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
Experience leading teams, projects, initiatives, or cross-functional groups.
Experience conducting provider or member outreach, case review, or data validation.
Deep experience with data validation and operational Quality Assurance (QA) techniques
Strong investigative, analytical, and communication skills.
Ability to manage sensitive member/provider interactions with professionalism.
Strong documentation and audit-readiness skills.
Ability to manage time-sensitive workflows while maintaining accuracy.
Proficiency in Microsoft Office and claims data tools.
Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.
Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.
Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.
Must have a deep understanding of financial principles.
Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.
Demonstrated ability to make informed decisions.
Strong verbal, written communication and presentation skills.
Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.
Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Nice To Haves

Master's Degree in Business Administration or Related Field
Experience interpreting managed care benefits, authorization processes, coding, and provider contract terms.
Experience in Medicaid, Medicare, and/or Commercial lines of business.
Experience with data validation or operational QA techniques.
Knowledge of FWA indicators, SIU protocols, and program integrity practices.

Responsibilities

Ensures that L.A. Care maintains a disciplined, consistent, and defensible pre-payment validation process supporting payment accuracy, program integrity, and member protection. Builds a strong preventive control environment by validating services before payment, ensuring SVU determinations are timely, reliable, well-documented, and integrated with upstream operational improvements.
Leads daily SVU operations, including member and provider contact workflows, service verification, documentation review, and adjudication hold/release decisions. Ensures SVU activities occur within established timeframes to avoid payment delays while maintaining thorough and accurate validation. Applies consistent criteria to verify whether billed services were received, ordered, properly represented, and appropriately billed. Ensures SVU staff follow standardized scripts, documentation requirements, and outreach protocols.
Oversees timely and professional outreach to members to validate service receipt, provider, date of service, and any concerns or discrepancies. Ensures referring and rendering providers are contacted for clarity on orders, referrals, documentation, or medical necessity questions when appropriate. Ensures escalations are addressed when discrepancies or concerning patterns are identified. Ensures high-quality communication that supports member trust, minimizes abrasion, and protects Protected Health Information (PHI).
Works closely with cross-functional key stakeholders to identify trends that may signal fraud, waste, abuse, overbilling, or systemic issues. Refers suspicious patterns to SIU or Payment Integrity with complete, documented findings. Ensures the SVU functions as a preventive control aligned with enterprise accuracy and program integrity goals. Supports the shift toward proactive cost avoidance and upstream error prevention.
Ensures validated claims are released for adjudication promptly and that holds are applied only when necessary. Partners with Claims Administration to establish clear criteria for what types of claims or services require SVU review. Collaborates with Configuration and Provider Network to ensure benefit and contract rules are accurately reflected in SVU criteria. Provides recommendations to improve system edits, benefits configuration, authorization processes, and provider education.
Ensures SVU findings are documented clearly, consistently, and in compliance with regulatory standards. Oversees development of dashboards tracking SVU volume, disposition categories, turnaround times, verification outcomes, and trend indicators. Identifies emerging issues and communicates upstream risks involving specific providers, services, benefit types, or claim categories. Prepares executive summaries and supports regulatory or audit inquiries related to SVU processes.
Continuously refines SVU criteria, outreach scripts, validation logic, and documentation workflows. Partners with operational teams to incorporate new benefit rules, system changes, or regulatory updates into SVU processes. Improves handoffs between cross -functional key stakeholders.
Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Manages, leads, trains, coaches, and develops staff to ensure accuracy, professionalism, and strong investigative skills. Ensures team members are trained in verification protocols, communication standards, confidentiality requirements, and documentation practices.
Creates a culture that values member respect, accuracy, proactive issue identification, and cross-functional collaboration. Drives accountability through transparent goals, consistent feedback, and measurable performance metrics. Supports a positive, collaborative culture that values accuracy, teamwork, transparency, and customer-focused operational excellence.
Ensures ongoing team development, cross-training, and readiness for regulatory, operational, or system-driven changes. Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.
Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.
Perform other duties as assigned.