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Manager Grievance &amp; Appeals (Provider Services) CalOptima CalOptima Health is seeking a highly motivated an experienced Manager, Grievance &amp; Appeals (Provider Services) to join our team. The Manager Grievance &amp; Appeals (Provider Services) will provide daily oversight and technical management for provider services, including provider disputes, provider grievances and provider appeal to ensure compliance with state, federal and accreditation standards applicable to CalOptima Health. The incumbent will work with CalOptima Health management staff and other affiliated health networks with a close interface to the program and process, including areas such as Utilization Management, Claims Administration, Delegation Oversight, Quality Improvement and health network relations. The incumbent will research complex claims problems, isolate root causes and partner with various entities for resolution. The incumbent will communicate with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community-based organizations and medical groups. Position Information: 
<ul>
<li>Department: GA - Provider Disputes </li>
<li>Salary Grade: 315 - $109,892 - $175,827 ($52.83 - $84.5322) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>50% - Program Oversight
<ul>
<li>Identifies and analyzes trends, collaborates with the Director to provide trends and makes recommendations for improvement.</li>
<li>Stays current on the local, state and federal health care environment, identifying issues that may impact CalOptima Health's programs as they relate to claims, provider disputes, grievances and provider appeals.</li>
<li>Develops, implements, maintains and reviews the adequacy of the CalOptima Health provider grievance systems, reporting, policies and functions to achieve stated goals, including, but not limited to, complaint resolution and timely responsiveness for all lines of business, to ensure compliance with all relevant regulatory requirements pertaining to provider disputes.</li>
<li>Works with the Audit and Oversight department and key departments to ensure internal departments and external partners (e.g., health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes.</li>
<li>Ensures timely and effective data collection, summarization, integration and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee, Quality Assurance Committee of the Board of Directors and other ad hoc reporting as required.</li>
<li>Serves as CalOptima Health's primary point of contact and subject matter expert related to provider services (disputes, grievances and appeals).</li>
<li>Participates in Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid (CMS) audits related to area of responsibility for all CalOptima Health programs. </li>
</ul>
</li>
<li>45% - Leadership
<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>Manages, hires, mentors and develops department staff.</li>
<li>Oversees the development and maintenance of internal policies and procedures and desktops to ensure compliance with all state and federal regulations for multiple lines of business.</li>
<li>Manages and makes recommendations on the development and maintenance of an effective dispute, appeals and grievance process and systems consistent with CalOptima Health policies and stated goals, including, but not limited to mechanisms to monitor provider disputes, grievances and appeals involving Legal, DMHC, DHCS, Independent Medical Review, Medi-Cal State Hearings, Office of Administrative Hearings and Appeals, CMS and external review agencies for CMS.</li>
<li>Partners with the management to ensure appropriate training and auditing tools are developed and maintained 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>Bachelor's degree in business administration, nursing, healthcare administration or related field PLUS 3 years of health care management experience in a related area of responsibility (provider disputes and appeals, claims administration, appeals and grievances) 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 leadership experience required. </li>
<li>Experience in health maintenance organization, Medi-Cal/Medicaid, Medicare Advantage, Medicare Part D, Special Needs Plans, Medicare-Medicaid Plans and/or the Program of All-Inclusive Care for the Elderly required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience with process improvement implementation.</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, work schedules that allow every other Monday or Friday off (9/80 schedule), 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=6357344&amp;targetURL=https://alliantbenefits.cld.bz/24caloptimacabenguide" target="_blank">2024 CalOptima Health Benefits Guide</a> and our <a href="https://apptrkr.com/get_redirect.php?id=6357344&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 16, 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/6357344" target="_blank">https://jobs.caloptima.org/jobs/manager-grievance-appeals-provider-services-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-cf7b2c04c4b10840a8654602344b5194

Manager Grievance & Appeals (Provider Services)

The Chief of Endocrinology will provide strategic leadership and direction for all aspects of the&nbsp;Division. The Division Chief will be responsible for all planning, policy, operations, and&nbsp;oversight of academic, research, and clinical programs of the Division. The Chief of Endocrinology&nbsp;will have financial authority over the division&nbsp; budget, including extramural research and&nbsp;philanthropic funding received and other financial matters for the division, in accordance with&nbsp;applicable University policies and practices. The Chief of Endocrinology will have discretion in&nbsp;the recruitment and retention of division faculty who will have a direct reporting line. Qualified&nbsp;candidates must possess a Doctor of Medicine (MD), Doctor of Osteopathic (DO) or equivalent degree&nbsp;from an accredited institution and be eligible for a University of Arizona academic appointment at&nbsp;the Associate or Full Professor rank. The Chief of Endocrinology will also play a prominent role in&nbsp;the establishment of a Diabetes Research Center with the support of an ongoing University of&nbsp;Arizona (UA) capital campaign and the continued development of an NIH - T32 training program in&nbsp;diabetes, endocrine, and metabolism.
The Endocrinology division is one of twelve within the Department of Medicine, which leads the&nbsp;University of Arizona, College of Medicine-Tucson in research funding, and has two residency&nbsp;programs, 15 fellowship programs including endocrinology, and numerous mentorship opportunities in&nbsp;multidisciplinary health science graduate programs. The College anchors the University of Arizona&nbsp;Health Sciences (UAHS) campus, which also houses the UA Colleges of Public Health, Pharmacy, and&nbsp;Nursing, as well as multiple research Centers of Excellence, and includes a research partnership&nbsp;with the Veterans Affairs (VA) Tucson Medical Center, which serves all Southern Arizona. The&nbsp;College inspires and trains individuals to become exemplary physicians, scientists and leaders who&nbsp;are life-long learners and inquisitive scholars. We embrace professionalism, innovation, and&nbsp;collaboration to optimize health and health care for all. The University of Arizona Health&nbsp; Sciences&nbsp;embodies the University’s priorities of engagement, partnership, innovation, and synergy in its&nbsp;world-class academic and research initiatives, with clinical facilities throughout Greater Tucson.&nbsp;Building on an established partnership with Banner Health, the fourth largest non-profit healthcare&nbsp;system in the U.S., the division and department are well- positioned as the sole academic health&nbsp;care provider in southern Arizona to provide transformative health care to the communities that we&nbsp;serve by achieving excellence in clinical care, education, and individual and team-based research.&nbsp;The incumbent will work collaboratively with the leaders of the College and Banner – University&nbsp;Medical Group (B-UMG) to further this tripartite mission and position the division for continued&nbsp;growth through innovation.
Duties &amp; Responsibilities:
<ul>
<li>Provide leadership and management of day-to-day operations of the Division of Endocrinology.</li>
<li>Responsible for recruitment, management, compensation, and retention of faculty in consideration of&nbsp;UA, UHSC, College, and B—UMG strategic plans and initiatives in balance of the multiple, tripartite&nbsp;mission of the University.</li>
<li>Collaborate with Academic Affairs and other educational offices at the College to ensure the&nbsp;division and their faculty are advancing the mission of the medical student, graduate student, and&nbsp;graduate medical education teaching programs.</li>
<li>Responsible for maintaining liaison with other clinical and/or basic science departments to foster&nbsp;an integrated teaching environment for the College.</li>
<li>Has the responsibility to support and expand research activities within the division, and across&nbsp;the Department, College and UAHS, working with key partners.</li>
<li>Provide leadership oversight and effective management of an active program of independent,&nbsp;extramurally funded basic, translational or clinical research in area of research&nbsp;expertise/specialization.</li>
<li>Is the clinical role model and leader of the division’s clinical activities and works with the&nbsp;Dean, Department Head, and the B—UMG CEO to coordinate the clinical activities of the division and oversee inpatient and outpatient clinical services.</li>
<li>Responsible for maintaining appropriate standards of care appropriate to the discipline.</li>
<li>Provide direct patient care in the inpatient and/or ambulatory (outpatient) setting as a licensed and fully credentialed provider as a member of Banner—University Medical Group.</li>
<li>Responsible for ensuring the fiscal accountability and sustainability of the division working with the&nbsp;College’s Business Affairs Office.</li>
<li>Responsible for encouraging and supporting diversity among the division’s constituents, creating an&nbsp;environment of professionalism, respect, tolerance, and acceptance and work in partnership with the Office of Diversity and Inclusion.</li>
</ul>
As a land-grant, Hispanic-serving institution and active NIH-partner for the All of Us Research program, the University of Arizona College of Medicine-Tucson champions diversity as a core value central to its&nbsp;mission. We are committed to promoting and supporting diversity and inclusion in our research, clinical&nbsp;and educational missions to meet the needs of the students, faculty, staff, and the communities we serve.&nbsp;We believe diversity at the University of Arizona College of Medicine-Tucson creates role models,&nbsp;broadens perspectives, combats negative stereotyping, and optimizes our ability to provide health care for&nbsp;all. We also respectfully&nbsp; acknowledge the University of Arizona is on the land and territories of Indigenous&nbsp;peoples. Today, Arizona is home to 22 federally recognized tribes, with Tucson being home to the&nbsp;O’odham and the Yaqui.
Outstanding UA benefits include health, dental, and vision insurance plans; life insurance and disability&nbsp;programs; paid vacation, sick leave, and holidays; UA/ASU/NAU tuition reduction for the employee and&nbsp;qualified family members; state and optional retirement plans; access to UA recreation and cultural&nbsp;activities; and more. Tucson, a UNESCO-designated city of gastronomy set in the high Sonoran Desert in&nbsp;the midst of five mountain ranges, offers a culturally rich scene, including opera, theatre and professional&nbsp;sports teams, as well as some of the top- rated K-12 schools in Arizona and the nation, boasting an&nbsp;average 340 sunny days a year in a warm dry climate ideal for year-round outdoor recreation.
Requirements
<ul>
<li>MD, DO, or equivalent.</li>
<li>Board certified by the American Board of Internal Medicine/Medical Subspecialties and eligible for&nbsp;unrestricted medical licensure in the State of Arizona.</li>
<li>Three to five years of progressively complex administrative experience (e.g., program leader,&nbsp;center/section director, etc.) in an academic medical center setting.</li>
<li>Demonstrated track record of distinction in teaching, clinical care, and/or research in an academic&nbsp;department of medicine or equivalent environment.</li>
<li>Demonstrated commitment to patient care, reflecting a service-oriented, team-based philosophy with&nbsp;hospital administration and health professional colleagues from all disciplines, departments, and&nbsp;specialties.</li>
<li>Successful track record of recruitment and development of faculty, trainees, and students.</li>
<li>A record of solid performance as a skilled manager with the ability to grow revenues, meet budgets,&nbsp;measure, and improve productivity and outcomes, and undertake appropriate business strategies to&nbsp;achieve division, unit, department and/or enterprise goals.</li>
<li>If the individual selected for employment does NOT currently hold a faculty title with The University of&nbsp;Arizona, College of Medicine-Tucson, they will be required to obtain faculty status. This will include&nbsp;obtaining letters of recommendation and review by the appropriate College review committee.</li>
</ul>

Division Chief of Endocrinology (Associate/Full Professor) (NTE/TE/T)

Holy Cross Medical Center Is Now Hiring! Immediate Openings:&nbsp; • Senior Financial Analyst • Accounting Assistant • Care Coordinator • Patient Advocate Apply: HolyCrossMedicalCenter.org&nbsp; Or call: (575) 751-5731 &nbsp;

Medical Assistant, Surgical Technician, Registered Nurse (RN), Certified Coding Specialist

<h3>Job Description</h3>
Job Description
 
Come join an exciting and innovative company that puts the “care” back in healthcare!
 
Why do Nursing Coordinators want to work here? The reason people love working for KabaFusion is because of the impact we have on our patients. Here, it doesn’t matter what your role is, you will be part of a team that works collaboratively to change lives. You will go home knowing you’ve made a difference and improved someone’s life. 
About us:
What started as a single pharmacy in 2010 has grown into KabaFusion becoming the largest privately held home infusion company in the country. We have a national network of pharmacies and nursing offices strategically placed to service 40+ states. Couple that with over 30 years of combined experience and it’s no wonder why KabaFusion is the industry leader in home infusion. 
About the role:
Our Nursing Coordinators have direct interaction with our patients and are the first voice they hear from our nursing department. In this role you will coordinate and schedule patient visits, manage patient charts, gather important documentation, and interact with providers as needed. 
Essential Duties &amp; Responsibilities: 
<ul>
<li>Obtains incoming outsourced agency nursing notes and invoices to match up dates and times, enters Patient Care Management System and forwards to QA Nurse for review. </li>
<li>Enters all scheduling data into the computer system in a timely manner and ensures that data is accurate and complete. </li>
<li>Assists with sending out physician plan of treatment and free form orders for signature and tracks for return, works with sales representatives to obtain timely signature as needed. </li>
</ul>
As a Nursing Coordinator, you bring: 
<ul>
<li>High school diploma or equivalent </li>
<li>3+ years of scheduling/coordinator experience </li>
</ul>
What we offer:
<ul>
<li>Benefits start on your 1st day of employment</li>
<li>401K w/ 4% Match – no waiting or vesting period</li>
<li>PTO / Floating Holidays / Paid Holidays</li>
<li>Company Paid Life Insurance, short term disability</li>
<li>3 Employee Assistance Programs to help with mental health / wellness </li>
<li>Learning &amp; Development Programs</li>
<li>Perks… includes discounts on travel, cell phone, clothing, and more…</li>
<li>Generous employee Referral Program</li>
</ul>
To learn more about KabaFusion, please visit our careers page: <a href="https://www.kabafusion.com/careers/" target="_blank">https://www.kabafusion.com/careers/</a>
 
KabaFusion is a mission driven company with a focus on innovation and patient care so, as a Nursing Coordinator, if that sounds like something you want to be a part of, then look no further.

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