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Programmer Analyst III Lubbock 41415BR High Performance Computing Center Position Description The Programmer Analyst III's role is to develop, test, analyze, and maintain software applications in support of business requirements. Major/Essential Functions 
<ul>
<li>Research, design, document, and modify software specifications throughout the production life cycle.</li>
<li>Supervise and/or lead the development of new systems, directing changes to existing systems and controlling the interfaces between the systems, initiating complex feasibility studies and making recommendations of the action to be taken.</li>
<li>Perform systems analysis, develops, and reviews programming code defined in project plans to meet design specifications, customer requirements, and/or applies vendor supplied upgrades.</li>
<li>Design, development, documentation, analysis, creation, testing, or modification of computer systems or programs, including prototypes, based on user or system design specifications.</li>
<li>Completes application modifications to enhance functionality, adapt to technology changes, and correct application errors.</li>
<li>Supervises and/or leads programming projects and initiatives, as assigned by management.</li>
<li>Completes other programming tasks, as assigned by management.</li>
<li>Adheres to all appropriate institutional policies (including IT Ops) and other relevant internal department policies.</li>
</ul>
 Required Qualifications Bachelor's degree with coursework in computer science, MIS, IT, or other related area plus three (3) years related full-time paid experience OR a combination of related education and/or experience. Applicants for this Security Sensitive Level II position will be subject to a criminal background check and must pass a drug and alcohol test after a conditional offer of employment has been extended, but before employment can be confirmed. Preferred Qualifications Bachelor's degree in Computer Science or a related degree field with coursework in computer science, management information systems, or information technology. 3 years of experience as a computer programmer, software engineer, or other related role. Requires analytical design skills, including process description, logic problem diagnostics, and problem-solving; programming languages; and application and database design and development concepts and standards. Employer will accept a bachelor's degree equivalency based on a combination of education and experience. Special Instructions to Applicant Minimum Hire Rate To apply, visit <a href="https://apptrkr.com/6317620" target="_blank">workattexastech.com</a> All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information or status as a protected veteran. Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-fdd102af9ca93b4bb658a7316bbd73f5

Programmer Analyst III

Claims Examiner CalOptima CalOptima Health is seeking a highly motivated Claims Examiner to join our team. The Claims Examiner will be responsible for analyzing and validating claim data elements and claims processing. The incumbent will be responsible for adhering to the regulatory and internal processing guidelines in conjunction with CalOptima Health policies and procedures related to claims adjudication. Position Information: 
<ul>
<li>Department: Claims Administration </li>
<li>Salary Grade: 301 - $47,840 - $64,584 ($23.00 - $31.0500) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>85% - Claims Support
<ul>
<li>Performs thorough review of pending claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.</li>
<li>Processes non-institutional claim types.</li>
<li>Corrects system generated errors manually prior to final claims adjudication.</li>
<li>Processes claims based upon CalOptima Health contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima Health policies and procedures.</li>
<li>Analyzes and validates Medi-Cal pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges and utilizes current billing code sets, including International Classification Diseases (ICD10) codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.</li>
<li>Validates eligibility and other possible health insurance coverage on the claim.</li>
<li>Alerts manager or supervisor of more complex issues that arise.</li>
<li>Processes claim exception reports as assigned. </li>
</ul>
</li>
<li>10% - Administrative Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>High school diploma or equivalent PLUS 1 year of related claims processing experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience processing online claims in a managed care environment. </li>
<li>Experience processing Medi-Cal claims.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6329575&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is July 11, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6329575" target="_blank">https://jobs.caloptima.org/jobs/claims-examiner-505-city-parkway-west-california-united-states-fd7ed77a-73a4-4bd2-9f12-47d82ac1ed30</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-a4cc42329aeb0d40b1127d796b9ce31e

Claims Examiner

Interdisciplinary Team Lead (Program Specialist) CalOptima CalOptima Health is seeking a highly motivated Program Specialist (Interdisciplinary Team Lead) to join our team. The Program Specialist (Interdisciplinary Team Lead) will be responsible for supporting the Manager PACE Center by holding primary responsibility for scheduling meetings and follow ups with the Interdisciplinary Teams (IDT), documenting attendance, recording decision-making, and managing authorizations for multiple IDT. The incumbent will interact with various clinical and non-clinical staff to coordinate participant care. Position Information: 
<ul>
<li>Department: PACE- Clinic </li>
<li>Salary Grade: 305 - $55,966 - $83,949 ($26.91 - $40.3601) </li>
<li>Work Arrangement: Full Office **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>95% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Coordinates calendars, meeting space, equipment and schedules to support IDT functions.</li>
<li>Serves as a scribe to all IDTs by tracking authorizations, service delivery requests and care coordination authorizations that are approved by the IDT.</li>
<li>Tracks and communicates to the Quality Improvement team the status of service delivery requests, including approved, denied or modified to ensure compliance with regulatory requirements.</li>
<li>Tracks and communicates the status of initial, semi-annual and annual assessments for all members of the IDT on behalf of the manager.</li>
<li>Assigns and tracks completion of PACE participant care plan approval.</li>
<li>Ensures completion of required documentation in electronic health records within 30-day requirement.</li>
<li>Serves as a liaison between manager and members of IDT and follows up on the progress of projects and activities assigned to other staff.</li>
<li>Determines the priority of matters of attention for the manager and redirects to supervisor, staff or handles matters directly as appropriate.</li>
<li>Provides back-up support to the Administrative Assistant by taking IDT minutes.</li>
<li>Maintains accurate and timely documentation in participant electronic health records.</li>
<li>Provides administrative support for specific and/or ongoing projects, such as regulatory audits by generating reports, logs, calendars and mailings as appropriate.</li>
<li>Attends and participates in in-services, staff meetings and case conferences as indicated. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, health care administration, public health, public policy or related field PLUS 2 years of administrative experience in a health care setting required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>1 year of experience working with the frail or elderly population required with relevant experience within the last 3 years required. </li>
<li>CPR and First-Aid Certification required or must be obtained within six (6) months of date of hire.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>N/A</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6322849&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is July 8, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6322849" target="_blank">https://jobs.caloptima.org/jobs/interdisciplinary-team-lead-program-specialist-pace-garden-grove-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-57516b5c0f361d49a2dff80b78f313ae

Interdisciplinary Team Lead (Program Specialist)

Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I) CalOptima CalOptima Health is seeking a highly motivated Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I) to join our team. The Sr Manager I for Fraud, Waste and Abuse (FWA) will be responsible for leading the team of CalOptima Health investigators to detect, investigate and mitigate FWA issues. The incumbent will ensure investigations are handled effectively and in a timely manner and will engage with regulatory agencies. The incumbent will partner with the director in long-term strategy planning to accomplish the department's goals and mission to enhance the program and payment integrity of the organization. Position Information: 
<ul>
<li>Department: Office of Compliance </li>
<li>Salary Grade: 316 - $120,881 - $193,410 ($58.12 - $92.9856) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>45% - Leadership Functions
<ul>
<li>Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.</li>
<li>Hires, manages, trains, supports, develops and evaluates direct reports.</li>
<li>Directs work assignments, measures results and initiates personnel actions.</li>
<li>Ensures that team members are trained and equipped with the necessary skills and resources.</li>
<li>Collaborates with the director in departmental budgeting activities.</li>
<li>Oversees the planning, scoping and execution of audits and the development of audit tools; ensures alignment with organizational goals and regulatory requirements.</li>
<li>Oversees the planning, scoping and execution of investigations and the development of investigative tools; ensures alignment with organizational goals and regulatory requirements.</li>
<li>Assists the director on development of the annual FWA risk assessment and Anti-Fraud, Waste and Abuse Plan.</li>
<li>Assists department leadership in the management of critical business risks by communicating best practices, promoting process improvement, and monitoring remediation activities. </li>
</ul>
</li>
<li>35% - Program Oversight
<ul>
<li>Provides expertise and guidance to staff, management and other department areas on sensitive and complicated program integrity concerns, oversight and referrals.</li>
<li>Creates and manages effective monitoring of ongoing investigations, including quality control, timeliness and business relations to continually evaluate FWA related activities.</li>
<li>Performs reviews of investigations for sufficiency of content and documentation and escalates where appropriate.</li>
<li>Prepares timely and accurate reporting on investigations, including scope, activities, methodologies, observations, deficiencies, recommendations and remediation activities.</li>
<li>Presents investigative reports including findings, risks and recommendations to senior management.</li>
<li>Collaborates with business areas to enhance systems, workflows and internal controls.</li>
<li>Identifies benchmarking standards (leading practices) for identifying potential control gaps and/or opportunities for improving efficiency and compliance.</li>
<li>Proposes recommendations for enhancing operational efficiency and identifying other areas of improvement.</li>
<li>Provides excellent customer service by addressing concerns promptly and delivering actionable, professional insights. </li>
</ul>
</li>
<li>15% - Investigative Activities
<ul>
<li>Performs investigation activities for complex cases.</li>
<li>Partners with staff in performing investigations of difficult cases. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, accounting, health information management, or another related field PLUS 5 years of relevant work experience in health care investigations required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>5 years of managerial experience within a managed care health plan in audits or investigations, or as an outside consultant engaged to perform audit work for a managed care health plan required. </li>
<li>Have access to means of transportation for work away from the primary office approximately 15% of the time.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Master's degree.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) or similar certification completion, currently pursuing a related certification or has completed more than half of the requirements towards a certification.</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6305723&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 30, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6305723" target="_blank">https://jobs.caloptima.org/jobs/sr-manager-fraud-waste-and-abuse-investigations-sr-manager-i-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-7b45ba9efc4d8747a6f8e14e16e01d8e

Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I)

The St. Louis Jewish Community Center is committed to comprehensive, vibrant and high-quality programming to serve the St. Louis Jewish and surrounding community.&nbsp; With three dynamic campuses, including a resident camp, our programs are designed to engage, educate, and inspire individuals and families across all ages and backgrounds.
The Chief Program Officer (CPO) is a key member of the Executive Team and is responsible for the vision, development, implementation, and evaluation of several programs across the agency’s campuses. The CPO will supervise Program Directors for several of the agency’s core programming areas and lead the expansion of our reach into the broader community.&nbsp;&nbsp;&nbsp; This position will provide leadership and direction, and the CPO will sit on the agency’s Executive Team.
Position Summary 
The CPO leads the development, implementation and evaluation of core programs and services.&nbsp; The CPO is responsible for the successful outcome of their programs by ensuring that their staff execute their programs at a high level.&nbsp; The CPO will have accountability for developing programming strategy, program evaluation, ROI, and the development of programming staff.&nbsp; Program evaluation will be based upon quantitative and qualitative measures.&nbsp; The CPO will be accountable for the development of partnerships across the community with other Jewish professionals, lay leaders, and community leaders.&nbsp; The successful CPO will mentor and inspire future programming leadership.&nbsp; The CPO may also represent the Center and CEO and participate with board activities as appropriate.
The Chief Program Officer (CPO) is a key executive leader responsible for the strategic oversight and performance of The J’s core programmatic areas of: Early Childhood Education, Day Camp, Resident Camp (Camp Sabra, Sports and Aquatics
Essential Duties and Responsibilities:
<ul>
<li>Vision and Strategy: 
	Create and articulate a compelling programming vision that expands the agency’s reach within the St. Louis Jewish and broader community, including the development of innovative community programming and strategic partnerships with other agencies.</li>
<li>Program Development &amp; Improvement: 
	Develop and implement strategies to enhance program participation, financial outcomes, and overall impact. Identify and execute improvements to ensure effective and efficient use of organizational resources.</li>
<li>Organizational Planning: 
	In collaboration with the CEO and board members, participate in strategic planning and organizational development activities to include presentation of information related to resource management, internal capacity, timelines for implementation and organizational direction.</li>
<li>Leadership &amp; Supervision: 
	Supervise, mentor, inspire and hold Program Directors accountable for successful financial and program outcomes at the Staenberg Family Complex, Marilyn Fox Building, and Camp Sabra. Provide ongoing performance feedback and coaching.</li>
<li>Customer Service &amp; Experience: 
	Deliver and promote a culture of excellent customer service to internal and external stakeholders. Develop and monitor performance measures to evaluate service outcomes against goals.</li>
<li>Staff Development: 
	Support the professional growth of staff through performance evaluations, mentoring, and tailored development plans.</li>
<li>Program Evaluation: 
	Lead the development and implementation of evaluation tools to assess program alignment with mission, goals, and desired outcomes using both qualitative and quantitative measures.</li>
<li>Board &amp; Committee Engagement: 
	Coordinate effectively with lay leadership and board committees. Present program outcomes and insights to the Board of Directors and participate in key governance activities.</li>
<li>Reporting &amp; Communication: 
	Oversee the preparation of program participation and impact reports. Collaborate with the Marketing Director to ensure clear, effective communication to members, the Jewish community, and the broader St. Louis area.</li>
</ul>
Qualifications
Education &amp; Experience
<ul>
<li>Bachelor’s degree required; Master’s degree (MBA, MPA, MSW, or related) preferred. 10+ years of progressively responsible leadership experience in nonprofit, educational, community service, or for profit organizations. Proven track record of developing for profit or mission-driven programs.</li>
<li>Expertise with program design, project management and project implementation.&nbsp; Contract negotiation skills with demonstrated ability to effectively manage multiple processes, programs and projects.</li>
<li>Relevant computer skills, including proficiency in Microsoft Office Suite. Experience with Salesforce is a plus.</li>
<li>Proficiency in evaluation tools, performance metrics, and data-driven management.</li>
<li>Prefer experience in board and lay committee interface.</li>
</ul>
Skills &amp; Competencies
<ul>
<li>Strategic thinker with strong analytical, planning, and budgeting skills. Outstanding interpersonal, communication, and presentation abilities. Adept in program innovation, change management, and stakeholder engagement.</li>
<li>An ability to anticipate and solve practical problems or resolve issues.</li>
<li>Excellent communication skills – both written and oral – along with strong leadership, interpersonal, and supervisory abilities. Strong background in staff supervision, budget management, and program evaluation. Demonstrated success managing diverse program portfolios and large teams. Knowledge of Jewish culture, traditions, and community dynamics is highly desirable. Ability to multitask and prioritize appropriately.</li>
</ul>
Equal Opportunity Employer 
The J celebrates diversity and is committed to creating an inclusive environment for all employees and community members.

Chief Program Officer 

Program/Policy Analyst Sr (Medi-Cal Compliance) CalOptima CalOptima Health is seeking a highly motivated Program/Policy Analyst Sr (Medi-Cal Compliance) to join our team. The Program/Policy Analyst Sr (Medi-Cal Compliance) will coordinate and maintain CalOptima Health's relationship with regulatory agencies and ensure CalOptima Health and its First Tier, Downstream and Related Entities (FDRs) comply with all appropriate standards, regulations, contractual provisions, federal waivers and laws. Specifically, the incumbent works to enhance and strengthen CalOptima Health's policy infrastructure, platform and strategies at the state level, including contract compliance, statutory and regulatory obligations with the Department of Health Care Services (DHCS). The incumbent requires the ability to complete a variety of independent detailed analyses, including the development, review and response to corrective action plans. The incumbent will be responsible implementing Corrective Action Plans (CAPs), supporting regulatory audits, validating regulatory guidance and developing regulatory communications for CalOptima Health stakeholders. The incumbent will interact with CalOptima Health's executives and department management, FDR's management, legal counsel and state and federal regulatory agencies. The incumbent will also support other key CalOptima Health staff on related projects. Position Information: 
<ul>
<li>Department: OOC - MediCal Regulatory Affairs &amp; Compliance </li>
<li>Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>85% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Works with all of CalOptima Health's departments in response to inquiries, problem-solving and promoting CalOptima Health's mission and message.</li>
<li>Assists in the management of CalOptima Health's daily relationship with the DHCS for CalOptima Health's Medi-Cal program.</li>
<li>Maintains open lines of communication to ensure the ongoing trust and confidence of regulators in the program and management.</li>
<li>Researches, analyzes and makes recommendations regarding the policy implications of major initiatives for CalOptima Health's Medi-Cal program, e.g., integration of new benefits and populations.</li>
<li>Works with business areas at all levels of leadership to validate regulatory communications from regulators impacting CalOptima Health's Medi-Cal program.</li>
<li>Supports process improvements for the Office of Compliance department.</li>
<li>Serves as a Medi-Cal regulatory subject matter expert and lead for CalOptima Health's compliance issues and investigations.</li>
<li>Supports management in the readiness, coordination, oversight and remediation of regulatory audits, including but not limited to validating business area submissions, additional audit requests and written daily reports.</li>
<li>Researches and responds in a professional manner to questions pertaining to the Medi-Cal program.</li>
<li>Works with the director and manager with interactions and responses to regulatory representatives on compliance-related issues as needed.</li>
<li>Reviews and retains working knowledge of Medi-Cal policies and procedures related to assigned programs and projects.</li>
<li>Assists in the creation of communications and strategic alliances with regulators.</li>
<li>Researches and keeps current on the local, state and federal health care environment and health policy, identifying issues that may impact CalOptima Health's Medi-Cal program.</li>
<li>Coordinates the maintenance of public program benefit updates for accurate and consistent application by CalOptima Health and its provider community.</li>
<li>Participates and represents CalOptima Health in meetings and calls with regulators and associations and summarizes key points and impact to CalOptima Health's Medi-Cal program as needed. </li>
<li>10% - Administrative Support</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Initiates, facilitates and promotes activities to foster compliance awareness and encourages the reporting of compliance issues within the organization and related entities. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned.</li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in health services administration, public health, public policy or a related field PLUS 4 years of experience in government, public or government affairs role in health care compliance or health plan requirements required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Master's degree. </li>
<li>Experience working with regulatory agencies in California. </li>
<li>Experience with Medi-Cal regulatory requirements and/or compliance in the areas of Customer Service, Grievance &amp; Appeals, Quality Improvement, Case Management, Claims Administration and/or Utilization Management. </li>
<li>Certification in Healthcare Compliance (CHC) or other compliance related certifications such as Certified Compliance and Ethics Professional.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>n/a</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6296744&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 25, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6296744" target="_blank">https://jobs.caloptima.org/jobs/program-policy-analyst-sr-medi-cal-compliance-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-c10c0223e159b943b7243c210753f920

Program/Policy Analyst Sr (Medi-Cal Compliance)

Certified Coding Specialist Sr (HCC-Medicare and Medi-Cal) CalOptima CalOptima Health is seeking a highly motivated Certified Coding Specialist Sr (HCC-Medicare and Medi-Cal) to join our team. The Certified Coding Specialist Sr (HCC-Medicare and Medi-Cal) will be responsible for assisting with all Hierarchical Condition Categories (HCC) projects and Medi-Cal Annual Wellness Visit Initiative Program. The incumbent will handle risk adjustment-related activities to ensure the Centers for Medicare &amp; Medicaid Services (CMS) and Department of Health Care Services (DHCS) coding and documentation guidelines are met. The incumbent will assist in improving risk score performance through collaboration with CalOptima Health's health networks, contracted providers and Program of All-Inclusive Care for the Elderly (PACE) providers. The incumbent will substantiate and verify the member's medical records using International Classification of Diseases (ICD)-10 Clinical Modification (CM) official guidelines for coding and reporting during the review process. The incumbent will verify the accuracy, completeness and appropriateness of diagnosis codes based on the medical documentation provided. As part of the medical records review, travel may be required to physician offices or physician medical groups throughout Orange County. Position Information: 
<ul>
<li>Department: Financial Analysis </li>
<li>Salary Grade: 309 - $68,015 - $108,824 ($32.70 - $52.3192) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>80% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Reviews and assesses the accuracy, completeness, specificity and appropriateness of diagnosis codes based on documentation and creates tools/tip sheets for audit staff to utilize for future audits based on findings.</li>
<li>Conducts in depth retrospective and prospective medical record audits to assess the accuracy of ICD-10 CM coding for chronic conditions as it pertains to HCC for CalOptima Health Community Network (CHCN), PACE providers and delegated health networks.</li>
<li>Tracks all network HCC activities, including training, audit results and evaluating future outcomes, which includes monitoring performance improvement of network providers by observing patterns and trends and recommending solutions to the manager.</li>
<li>Reviews medical record information to identify all appropriate coding CMS HCC categories and DHCS coding and monitors the DHCS and CMS websites for updates.</li>
<li>Reviews additional data identified from audits to ensure timely data entry for CMS sweeps.</li>
<li>Identifies providers for education and training opportunities following ICD-10-CM coding guidelines based on HCC audit results and Medi-Cal Annual Wellness Visit Initiative Program and reports findings to the Manager.</li>
<li>Assists with CMS Risk Adjustment Data Validation (RADV) and Office of Inspector General (OIG) audits, including workflow or data collection requirements and creating and maintaining HCC audit results when applicable.</li>
<li>Performs code abstraction on supported clinical documentation identified as opportunities through Natural Language Processing (NLP) software. </li>
</ul>
</li>
<li>15% - Administrative Support
<ul>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Assists manager in evaluating existing reports for PACE members provided by CMS and collaborates with Financial Analysis to create any custom report required to assist with audits. </li>
</ul>
</li>
<li>5% - Other-
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in public health, business administration or related field PLUS 5 years of risk adjustment coding and chart audit/quality experience in a managed care or health care environment required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>Have access to means of transportation for work away from the primary office approximately 20% of the time required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Registered Health Information Technician (RHIT) or Certified Risk Adjustment Coder (CRC). </li>
<li>Experience with conducting presentations and performing physician education.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>Current Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) required. Certification is required to be current and maintained during employment.</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6299515&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 26, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6299515" target="_blank">https://jobs.caloptima.org/jobs/certified-coding-specialist-sr-hcc-medicare-and-medi-cal-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-d4deeaad9bc4a74cb61631e4900eb19a

Certified Coding Specialist Sr (HCC-Medicare and Medi-Cal)

Financial Analyst IV (Decision Support) CalOptima CalOptima Health is seeking a highly motivated Financial Analyst IV (Decision Support) to join our team. The Financial Analyst IV (Decision Support) will be responsible for providing analysis, guidance and expert knowledge on health care finance for various departments within CalOptima Health. Working independently, the incumbent will lead large-scale analytical initiatives and develop report suites and financial models used to forecast medical cost trends. The incumbent will provide support for provider contract negotiations, assess actuarial rate development studies, participate in annual budgeting functions, provide ad-hoc analytic support as needed and act as a resource to staff and other consultants within the department. The incumbent will evaluate various complex issues, perform detailed analysis and communicate well reasoned solutions to all levels of management within CalOptima Health. The incumbent will work with large amounts of claims, enrollment and provider data. Position Information: 
<ul>
<li>Department: Financial Analysis </li>
<li>Salary Grade: 314 - $99,902 - $159,843 ($48.03 - $76.8476) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>95% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Researches, assesses and develops advanced tools, models, reports and approaches to increase the accuracy and timeliness of data-driven work projects.</li>
<li>Develops medical expense, revenue and enrollment projections to support the budget process.</li>
<li>Develops financial models and reports to support provider contract negotiations.</li>
<li>Develops return on investment and business case analyses for program initiatives under consideration by management.</li>
<li>Provides clinical and utilization analysis to assist Medical Management with improving outcomes and quality of care for CalOptima Health members.</li>
<li>Collaborates with the Data Warehouse team to design and recommend improvements to the data warehouse.</li>
<li>Provides support and analyses around risk adjustment.</li>
<li>Mentors, trains and serves as a lead for analytical staff.</li>
<li>Designs, develops, implements and maintains report suites and dashboards for all levels of CalOptima Health management.</li>
<li>Serves as a subject matter expert around one or more of the following areas: Medi-Cal provider rate methodology, Medicare provider rate methodology, Department of Health Care Services (DHCS) revenue, Centers for Medicare &amp; Medicaid Services-Medicare Advantage (CMS-MA) revenue, population health member cohort identification, industry standard approaches to health care cost service categorization and metrics. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, finance, economics, actuarial sciences or related field PLUS 6 years of experience working with health care finance reporting and analytics in a medical group, hospital or health plan setting required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>3 years of experience in Provider Contract Modeling required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience working with commercial, Medi-Cal and Medicare large payer data sets and related pricing information that is publicly available. </li>
<li>Experience developing annual organizational budgets, forecasts and financial modeling. </li>
<li>Experience using Tableau and/or Microsoft SQL Server.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6299502&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 26, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6299502" target="_blank">https://jobs.caloptima.org/jobs/financial-analyst-iv-decision-support-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-f3569a1ca984034796c2553e8b161065

Financial Analyst IV (Decision Support)

Buyer, Sr. CalOptima CalOptima Health is seeking a highly motivated Buyer Sr to join our team. The Buyer Sr will handle complex purchasing assignments such as formal bidding that involves technical specifications and complex evaluation processes. The incumbent will conduct vendor negotiations to obtain the best pricing and a high level of service quality for the organization, conduct contract administration activities to ensure compliance with contact law and CalOptima Health policies, provide subject matter expertise and guidance to team members. Position Information: 
<ul>
<li>Department: Procurement &amp; Vendor Management </li>
<li>Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>85% - Program Support
<ul>
<li>Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Conducts formal and informal bid process by using tools such as Request for Proposal (RFP), Request for Quotation (RFQ), Request for Qualifications (RFQu) and Invitation for Bid (IFB).</li>
<li>Conducts post bid debriefing with unsuccessful bidders.</li>
<li>Negotiates contract pricing, terms and conditions with successful bidders.</li>
<li>Conducts bi-weekly contract review meetings with business owners.</li>
<li>Reviews invoices and vendor progress reports.</li>
<li>Coordinates vendor management activities and meetings in conjunction with business owner.</li>
<li>Prepares contract amendments, contract terminations and close-out activities.</li>
<li>Ensures timely renewals of contracts and amendments.</li>
<li>Assists business owners in determining appropriate contract types.</li>
<li>Reviews and processes purchase orders.</li>
<li>Enforces internal purchasing, contract administration, and travel policies and procedures.</li>
<li>Researches, interviews, and identifies best-in-class vendors.</li>
<li>Contacts vendors to perform follow-up on orders and expedite or delay orders as needed.</li>
<li>Provides training and support for internal users on purchasing systems.</li>
<li>Serves as a subject matter expert and provides guidance to other team members. </li>
</ul>
</li>
<li>10% - Administrative Support
<ul>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Assists departments in development of purchasing specifications or scopes of work.</li>
<li>Develops and distributes department reports. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Minimum Qualifications: 
<ul>
<li>High School diploma or equivalent PLUS 5 years of purchasing related experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Bachelor's degree in business administration or related field. </li>
<li>Professional certification from a national association (e.g., Institute for Supply Management (ISM) or National Institute of Governmental Purchasing (NIGP)). </li>
<li>Experience with Novatus, Ariett, BidSync or GP Dynamics. </li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6294589&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 25, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6294589" target="_blank">https://jobs.caloptima.org/jobs/buyer-sr-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-d0b0bd873a15ab43ac36a6d43607460d

Buyer, Sr.

Director, Medicare Program Development (Director III) CalOptima CalOptima Health is seeking a highly motivated Director, Medicare Program Development (Director III) to join our team. The Director III (Medicare Program Development) will be responsible for leadership, plan management and operations of CalOptima Health's Medicare lines of business, including the Program of All Inclusive Care for the Elderly (PACE) health plan operations. The incumbent will provide direction to CalOptima Health's departments to ensure compliance with regulatory agencies such as the Centers for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). The incumbent will collaborate with the Operations Management, Clinical Operations, Regulatory Relations and Finance departments, including but not limited to Customer Service, Grievance and Appeals, Medical Management, Provider Network Operations, Strategic Development, Compliance and Regulatory Affairs and subcontracted providers and health networks. The Director III will interact with all levels of CalOptima Health's staff, members, providers, regulatory agencies, advisory committees and representatives of other agencies as needed. Position Information: 
<ul>
<li>Department: Operations Management </li>
<li>Salary Grade: 322 - $192,386 - $307,817 ($92.49 - $147.9891) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>50% - Leadership Functions
<ul>
<li>Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.</li>
<li>Hires, supervises, develops, counsels and reviews the performance of department staff.</li>
<li>Supports the development of reports and presentations to CalOptima Health's Board of Directors, as needed.</li>
<li>Utilizes matrix management, directs and coordinates staff throughout the organization in the implementation of strategic work plans, development and implementation of new benefits or other initiatives for health plan operations, including but not limited to CMS Five Star Program operational initiatives and improvement activities.</li>
<li>Ensures implementation of Medicare and PACE program changes to comply with CMS regulatory requirements and is responsible for communication with stakeholders to implement such changes.</li>
<li>Ensures timely filing and compliance with CMS reports and data submissions.</li>
<li>Reviews and recommends approval of OneCare program and PACE health plan operations policies and procedures by the Executive Director and executive leadership. </li>
</ul>
</li>
<li>45% - Program Oversight
<ul>
<li>Directs and leads all business operations associated with the Medicare lines of business operations and supports certain PACE health plan operations, including coordination with and oversight of delegated health networks, contracted providers and contracted vendors.</li>
<li>Directly leads Medicare Programs outreach and retention function including developing strategies designed to expand community outreach and retention of current OneCare members.</li>
<li>Reviews and monitors Medicare programs and PACE program financial performance, provides recommendations and develops action plans.</li>
<li>Develops and monitors strategies and tactics for business development, new member enrollment and member retention in Medicare and PACE programs.</li>
<li>Supports Medicare annual bid submissions, including project management, supplemental benefit development and coordination with external actuary firm(s) and internal departments to complete and submit bids on time for Medicare and PACE programs.</li>
<li>Oversees the development of strategic plans, work plans and other initiatives for the OneCare and PACE program health plan operations.</li>
<li>Collaborates with Finance and other departments to improve activities for Medicare Risk Adjustment Factor (RAF) improvement activities for applicable programs.</li>
<li>Collaborates with internal departments in the implementation and oversight of community and member outreach activities designed to maximize visibility of Medicare programs including OneCare and PACE.</li>
<li>Partners with staff from across the organization to research specific issues as necessary to develop and analyze solutions and make policy or programmatic recommendations to address operational issues.</li>
<li>Reviews reports for submission to CMS, CalOptima Health's Board of Directors, executive leadership and others, as needed.</li>
<li>Facilitates monthly operations meetings to review Medicare and PACE program medical, financial and administrative operations.</li>
<li>Communicates the plan's operational issues, ensures adherence to work plans, identifies problem areas and develops solutions to issues or problems.</li>
<li>Collaborates with Medicare Programs Sales and Marketing and Communications departments in the development of marketing and enrollment strategies and tactics for increasing Medicare and PACE program enrollment and retention. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration or related field PLUS 7 years of experience in a management position of a health insurance plan, Independent Physician Association (IPA), managed care organization or public agency serving Medicare and Medicaid (Medi-Cal) populations required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. </li>
<li>7 years of progressive leadership experience, including direct supervision of staff required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Master's degree. </li>
<li>Medicare Advantage health plan operations, Medicare Advantage health maintenance organization (HMO) special needs plans (SNP), Medicaid or Medi-Cal and PACE program operations experience. </li>
<li>Project management experience.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6281703&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 20, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6281703" target="_blank">https://jobs.caloptima.org/jobs/director-medicare-program-development-director-iii-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-7afb9ea777e68d4fab491cabeb4bb238

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