Job Description
Department(s): Operations Management
Reports to: Executive Director (Medicare Programs)
FLSA status: Exempt
Salary Grade: R - $144,000 - $237,864
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 on Thursday, October 19, 2023 at 11:59 PM. 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.
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 the Position
The Director II (Medicare Program Development) will be responsible for leadership, plan management and operations of the 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 coordinate with Operations Management department, clinical operations, regulatory relations, finance and subcontracted providers and health networks. The incumbent will interact with all levels of CalOptima Health's staff, members, providers, regulatory agencies, advisory committees and representatives of other agencies as needed.
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.
• Coordinates all business operations associated with the Medicare lines of businesses operations, and PACE health plan operations, including coordination with and oversight of delegated health networks, contracted providers and contracted vendors.
• Under the direction of the Executive Director, reviews and monitors Medicare programs and PACE program financial performance; provides recommendations and develops action plans.
• Monitors and develops strategies and tactics for business development, new member enrollment and member retention in Medicare and PACE programs.
• 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.
• Hires, supervises, develops, counsels, and reviews performance of department staff.
• Oversees the development of strategic plans, work plans and other initiatives for the OneCare and PACE program health plan operations.
• Supports the development of reports and presentations to CalOptima Health's Board of Directors, as needed.
• Utilizes matrix management, directs and/or 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 Hierarchical Condition Category (HCC) maintenance and improvement activities.
• Coordinates data mining and data analysis activities for contracting and HCC improvement activities for applicable programs.
• Collaborates 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.
• Supports monthly operations meetings to review Medicare and PACE program medical, financial and administrative operations.
• Communicates the plan's operational issues; ensures adherence to work plans, identifies problem areas, develops solutions to issues or problems.
• Ensures implementation of Medicare and PACE program changes to comply with CMS regulatory requirements and is responsible for communication with stakeholders implement such changes.
• Ensures timely filing and compliance with CMS reports and data submissions.
• Reviews and recommends approval of OneCare program and PACE health plan operations policies and procedures by the Executive Director and senior leadership.
• Collaborates closely 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.
• Completes other projects and duties as assigned.

Experience & Education:

• Bachelor's degree in Business Administration or related field required.
• 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.
• 4 years of progressive leadership experience, including direct supervision of staff 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:

• Master's degree.
• Medicare Advantage health plan operations, Medicare Advantage health maintenance organization (HMO) special needs plans (SNP), Medicaid or Medi-Cal and PACE program operations experience.
• Project management experience.

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 job, employee may be required to move about the organization and to travel 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 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 or laptop case while traveling, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting. Occasional travel to off-site locations is required.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Off-site work environment varies upon location.

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 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. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
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 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/4395
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