CalOptima

Department(s): Provider Data Management Services. The Sr Manager I (Provider Data Management Services) will manage all workflows and operations within the Provider Data Management Services (PDMS) department to ensure accurate claims payment, timely data configuration, network adequacy and compliance.. Manages provider data management system and oversees vendor relations for provider data management system maintenance.. Develops, establishes and updates department processes, policies, procedures and desktop protocols as needed to maintain quality controls and guide the operation of PDMS.. Provider data management/configuration experience.

data management

Posted Date 2/2/2024 Department(s): Provider Data Management Services Reports to: Director II FLSA status: Exempt Salary Grade: P - $117,000 - $192,390 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 Friday, February 16, 2024 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. <ul><li>This position is eligible for partial telework in California.** </li></ul>About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you’re looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About The Position The Sr Manager I (Provider Data Management Services) will manage all workflows and operations within the Provider Data Management Services (PDMS) department to ensure accurate claims payment, timely data configuration, network adequacy and compliance. The incumbent will be responsible for the overall stewardship of the provider data within the organization, manage the end-to-end provider data operations processes, facilitate process improvement and data and support new systems implementation and updates. The incumbent will interface with internal and external stakeholders and must be process and data oriented while maintaining compliance and managing to industry standards. Duties & Responsibilities <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>Hires, manages, trains, reviews and sets goals for the department and staff. </li><li>Maintains the integrity of the provider data and configuration for all network and non-network providers, ensuring all provider information is entered accurately, timely and efficiently to provide for proper claims adjudication, provider directory output and member access.</li><li>Leads and manages a team responsible for maintaining accurate provider data within the provider data system, ensuring compliance with industry regulations and meeting organizational objectives while managing operational metrics, improving outcomes, implementing new strategies and sharing operational resources to bring results to expectations.</li><li>Reviews, interprets and implements regulatory requirements; participates in audit activities monthly, quarterly and annual data audit findings to respond within required timeframes; ensures data errors are resolved and coordinates with cross-functional departments as needed when there is organization-wide impact. </li><li>Leads provider data initiatives internally and externally, ensures delegated networks and internal departments adhere to data procedures and protocols and collaborates as needed to improve processes, reduce claims and grievance issues and enhance access to care. </li><li>Manages provider data management system and oversees vendor relations for provider data management system maintenance.</li><li>Collaborate with Contracting, Provider Relations, Credentialing, Claims and Regulatory Compliance Affairs to gather and synthesize requirements, establish data standards and monitor data integrity and process flow effectiveness.</li><li> Identifies issues/gaps and collaborates with functional areas, including Quality Improvement, Information Technology Services (ITS), Operations Management and external constituents to optimize operational efficiencies by leading the implementation of process improvements.</li><li>Oversees change management and communication of changes within provider data configuration impacting other departments and reports, including the Department of Healthcare Services 274 file, auditing reports, provider directories, provider termination reports and internal Core reports. </li><li>Develops work plans, requirements documents and tracking documents to support network growth and changes while ensuring ongoing data accuracy and integrity.</li><li>Reviews and manages existing workflows and implements changes for compliance.</li><li>Monitors, tracks and reports on established service level standards, compliance and regulatory requirements.</li><li>Manages programs to industry standards, staying up to date with regulations impacting this domain, collaborates in industrywide workgroups and meetings, implementing best practices while ensuring adherence and driving improvement in outcomes.</li><li>Develops, establishes and updates department processes, policies, procedures and desktop protocols as needed to maintain quality controls and guide the operation of PDMS.</li><li>Utilizes matrix management and coordinates staff throughout the organization in the implantation of strategic work plans or other initiatives for the CalOptima Health lines of business program operations. </li><li> Completes other projects and duties as assigned. </li></ul>Experience & Education <ul><li>Bachelor’s degree in Health Services, Business Administration or related field required.</li><li>5 years of experience in health care management required.</li><li>3 years of lead or supervisor experience required.</li><li>2 years of experience developing, planning and implementing in a lead role required.</li><li>Medi-Cal, Medicare and managed care experience required.</li><li>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></ul>Preferred Qualifications <ul><li>Provider data management/configuration experience.</li><li>Data mapping experience.</li><li>Health care operations experience (Customer Services, Claims, Credentialing, etc.).</li><li>Regulatory impact analysis experience. </li></ul>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. <ul><li>Physical demands: While performing duties of the job, employee is 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 and laptop to and from various locations. Employee must be able to communicate, particularly for regular phone use and face-to-face interaction.</li><li>Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Position also involves visits to provider offices which are equivalent to a typical physician’s office, hospital or other ancillary provider. </li></ul>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 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. Tracking Code 4534-117

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