Job Description
Department(s): Quality Improvement
Reports to: Manager Quality Improvement
FLSA status: Non-Exempt
Salary Grade: I - $61,000 - $99,110
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 Tuesday, October 3, 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 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 Auditor (Credentialing and Ongoing Monitoring) will conduct routine oversight and monitoring of all business functions related to credentialing within CalOptima Health, including oversight and on-going monitoring of providers/networks delegated for credentialing, which may include conducting audits. The incumbent will ensure compliance with state, federal and accreditation standards.
Duties & Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Assists in the development of credentialing checklists, audit tools and corrective action plan templates to address identified issues.
• Monitors and audits the internal credentialing files to ensure compliance and appropriate data entry into the credentialing system prior to credentialing files being placed on the clean list.
• Cultivates the relationship with the Credentialing Verification Organization (CVO) to ensure that providers are credentialed appropriately and timely, including the upload and download of provider data and documents.
• Conducts regular credentialing file reviews of completed credentialing files from our contracted Credentialing Verification Organization (CVO) to ensure compliance with state, federal and accreditation standards.
• Conducts monthly ongoing monitor checks on network providers.
• Assists with audits of the department's data entry activities into CalOptima Health's credentialing systems.
• Monitors credentialing performance reports (i.e., system modification reports, delegate monthly universe submission, etc.) to ensure compliance with state, federal and accreditation standards.
• Conducts validation audits for applicable areas of identified deficiencies to ensure all remediation efforts are effective and sustained.
• Assists in the development of corrective action plans to address any identified issues, which may include staff training, workflow updates and development of trainings materials and other documents to remediate noncompliance.
• Conducts training of the credentialing requirements and workflow, as needed.
• Compiles and summarizes data reports and writes audit results to internal committees and meetings with recommendations for improvement.
• Monitors the performance of our delegated provider groups/networks for credentialing to ensure CalOptima Health's contract requirements, as part of the delegation agreement, are met.
• Informs various departments and our delegates of any changes to regulatory requirements in relation to credentialing and re-credentialing.
• Participates in the pre-delegation audit for applicable areas to ensure delegated entities are able to perform the delegated activities prior to delegation, as needed.
• Participates in workgroups that address both clinical and non-clinical internal activities for which CalOptima Health must demonstrate improvement to meet its contractual requirements with the Centers for Medicare & Medicaid Services (CMS), Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC) and any other applicable entity.
• Assists in preparing presentations on credentialing compliance and performance to the Quality Improvement Health Equity Committee and to the Credentialing and Peer Review Committee, as needed.
• Serve as knowledge expert for assigned functional areas.
• Act as a liaison with other areas and business units.
• Completes other projects and duties as assigned.

Experience & Education:

• Bachelor's degree in a health care or related field required.
• 2 years of experience in credentialing or 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 is also qualifying.

Preferred Qualifications:

• Certified Provider Credentialing Specialist (CPCS) Certification.
• 1 year of auditing experience in the health care field.
• 2 years of experience within a managed care plan.

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. 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.

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.
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.
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/4382
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