Sr Manager, Operation and Business Configuration (Sr Manager I)
CalOptimaCalOptima Health is seeking a highly motivated
Sr Manager, Operation and Business Configuration (Sr Manager I) to join our team. The Sr Manager I for Operation and Business Configuration will function as a primary point of contact for the claims analytical support unit which consists of data analytics, process improvement and claims clearinghouse vendor oversight. The incumbent will collaborate with leadership on the development and implementation of analytical tools to identify department trends and will manage dedicated resources for the day-to-day operations to carry out the strategic and tactical execution of CalOptima Health business operations, ensuring compliance with business rules and government regulations.
Position Information:- Department: Claims Administration
- Salary Grade: 316 - $120,881 - $193,410 ($58.12 - $92.9856)
- Work Arrangement: Partial Telework
This position is eligible for telework in California.
Duties & Responsibilities:- 40% - Leadership Functions
- Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- 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.
- Hires, manages, trains, reviews and sets goals for the department and staff.
- Provides an environment that engages staff to fully participate in the overall department functions and workload balancing strategies.
- Develops and implements corrective action plans and trains staff as needed.
- Establishes and manages teams to a set of standards and governance to improve performance and support effective development and outputs.
- Provides management oversight and direction to Data Analysts Business team and serves as a liaison with internal and external entities such as Clearinghouse and health networks to ensure claims and authorization data load integrity.
- Provides management oversight and direction to the Clearinghouse Data Analyst team for intake requirements, analysis, conducting clearinghouse user acceptance testing and identifies impacts to systems and processes.
- Tracks and trends teams performances by way of dashboards, monitoring day-to-day activities of each claim operational areas, claims operational vendors and all clearinghouses.
- Represents Claims department and participates in regulatory audit presentations and demonstrations and conducts follow up remediation action items from the audit as needed.
- Works collaboratively with the Office of Compliance, Information Technology (IT), claims vendors and internal business teams on regulatory changes impacting claims adjudication and data integrity.
- Manages all claims vendor contract or scope of work (SOW) renewals and takes the lead for any request for proposal projects.
- Participates in CalOptima Health's enterprise projects impacting claims or operational payments and procedures/policies.
- Conducts claims presentation to staff, senior level leadership and CalOptima Health network providers.
- Maintains quality goals and production level within the department by collaborating with Claims department leadership teams and ensures that performance goals are consistently met and/or exceeded.
- Anticipates future demands of initiatives, strategic plans and regulatory updates and design/implement solutions to meet these needs.
- 35% - Program Oversight
- Ensures compliance with applicable internal policies and procedures and external state and federal regulations for multiple product lines (Medi-Cal, Medicare, Commercial (Covered California) and Program of All-Inclusive Care for the Elderly (PACE). Ensures overall claims adjudication is in accordance with the California Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) health plan regulatory requirements and guidelines.
- Intakes and reviews All Plan Letters (APL), CMS bulletins and regulatory guidance; oversees the development, timely and accurate implementation and publication/posting of claims-related regulatory requirements and reporting.
- Serves as the primary point of contact to answer questions related to system configuration business rules, various claim adjudication issues and resolves complex claims or benefit adjudication issues for department staff as well as other internal customers; responsible for the identification and resolution of provider claim issues including support of provider education and customer service staff in communications back to providers.
- Reviews and maintains department policies and procedures, recommends changes for more efficient operations, drafts new policies and procedures for director's review, communicates changes and updates to staff when appropriate.
- Stays current with regulatory guidelines impacting essential functions and data requirements.
- 20% - Technical Operations
- Develops the claims data standards and deploys automation tools to obtain and process claims data from different sources. Constructs datasets to analyze, inform, identify trends and support stakeholder decision-making.
- Identifies claims transaction inconsistencies, as well as implementation of controls and changes to systems and policies that support claims adjudication, thereby minimizing incorrect claims payment.
- Manages activities/service requests with Facets configuration, IT and EDI teams to scope, prioritize, and implement requirement changes.
- Manages and intakes all program implementation impacting Facets and systems supporting the Claims, Grievance and Appeals Resolution Services (GARS)/Provider Dispute Resolution (PDR) and Customer Service operations.
- 5% - Other
- Completes other projects and duties as assigned.
Minimum Qualifications:- Bachelor's degree in health information management, business administration, health administration or related field PLUS 5 years of experience in information technology business experience implementing claims adjudication programs and projects in a 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.
- 5 years of management/leadership experience that manages claims operation from intake to output of the claims payment required.
- 5 years of experience utilizing Microsoft technologies required.
Preferred Qualifications:Required Licensure / Certifications:Knowledge & Abilities:
- 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.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees/coalitions.
- 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.
Physical Requirements (With or Without Accommodations):- Ability to visually read information from computer screens, forms and other printed materials and information.
- Ability to speak (enunciate) clearly in conversation and general communication.
- Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
- Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
- Lifting and moving objects, patients and/or equipment 10 to 25 pounds
Work Environment:If located at the 500, 505 Building or a remote work location:
- Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
- There are no harmful environmental conditions present for this job.
- The noise level in this work environment is usually moderate.
If located at PACE:
- Work is typically indoors in a clinical setting serving the frail and elderly.
- There may be harmful or hazardous environmental conditions present for this job.
- The noise level in this work environment is usually moderate to loud.
If located in the Community:
- Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
- Employee will occasionally work outdoors in varied temperatures.
- There may be harmful or hazardous environmental conditions present for this job.
- The noise level in this work environment is usually moderate to loud. . click apply for full job details
