Job Description
Department(s): Provider Data Management Services
Reports to: Director, Provider Data Operations
FLSA status: Exempt
Salary Grade: O - 105,000 - 173,734


About CalOptima Health

CalOptima Health is the single largest health plan in Orange County, serving 880,000 members, or 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. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima Health.

About the Position

The Manager, Audit & Oversight (Provider Data) will oversee, monitor and audit provider data impacting business functions within CalOptima Health, as well as the health networks, to ensure compliance with state, federal and accreditation standards. The incumbent will lead a team of data quality auditors to review provider and network data for accuracy and integrity, provide findings, feedback and lead data quality improvement efforts internally and with health networks.


Duties & Responsibilities:

• 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.
• Oversees the development and maintenance of audit tools based on applicable regulatory audit protocols. Updates audit tools at least on an annual basis to reflect changes to regulatory audit protocols.
• Manages the development and maintenance of policies and desktop procedures for Audit & Oversight processes.
• Defines, measures and monitors provider data quality and sets up monitoring processes.
• Manages a team to audit internal Provider Services Data Management entries, provides feedback and identifies risks.
• Oversees accuracy of provider data related activities including directories, 274 files, FACETS integrity and collaborates with analytics team to develop monitoring/auditing reports.
• Monitors and tracks data audit requirements to ensure compliance with state and federal compliance.
• Works with the analytics team to integrate and reconcile various provider source data including third party commercial provider data, national data bases, medical associations and internal databases.
• Develops, facilitates and monitors improvement initiatives as assigned by the director.
• Provides written and oral summaries of audit analysis, as needed.
• Participates in and presents findings, deficiencies at Audit and Oversight committee and Network Adequacy committees as needed.
• Completes other projects and duties as assigned.

Experience & Education:

• Bachelor's degree in Healthcare Administration or related field required.
• 5 years of experience in audit process implementation in a healthcare organization or health plan required.
• 2 years of progressive management experience required.
• 1 year of experience in provider data required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

• Program management experience.
• Experience in healthcare, health plans, Medi-Cal, Medicare Advantage, Medicare Part D, Special Needs Plans (SNPs), Medicare-Medicaid Plans (MMPs), Provider Network, Provider Data Management Services, data management, auding, continuous improvement and/or a Program of All-Inclusive Care for the Elderly (PACE).

Physical Demands and Work Environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of the job, employee is required to move about the organization, as well as to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is often required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes. Employee must be able to communicate, particularly for regular phone use, in meetings, and face-to-face interaction. Specific vision abilities required by this job include close vision and the ability to adjust focus.

• Work Environment: Typical office environment with minimal to moderate noise levels, depending on the time of day, and controlled office temperatures.

About our Benefits & 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 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. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is an equal employment 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 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.

Job Location: Orange, California
Position Type:

To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4253

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