Director, Medicare Program Development (Director II)

Director, Medicare Program Development (Director II)

CalOptima

CalOptima Health is seeking a highly motivated an experienced Director, Medicare Program Development (Director II) to join our team. The Director II (Medicare Program Development) will be responsible for leadership, plan management and operations of 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 collaborate with the Operations Management, Clinical Operations, Regulatory Relations and Finance departments, including but not limited to Customer Service, Grievance and Appeals, Medical Management, Provider Network Operations, Strategic Development, Compliance and Regulatory Affairs 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.

Position Information:

Department: Operations Management

Salary Grade: 321 - $181,257 - $290,011 ($87.14 - $139.4282)

Work Arrangement: Partial Telework

**This position is eligible for telework in California.**

Duties & Responsibilities:

50% - 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, supervises, develops, counsels and reviews the performance of department staff.

Supports the development of reports and presentations to CalOptima Health's Board of Directors, as needed.

Utilizes matrix management, directs and 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.

Ensures implementation of Medicare and PACE program changes to comply with CMS regulatory requirements and is responsible for communication with stakeholders to 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 executive leadership.

45% - Program Oversight

Directs and leads all business operations associated with the Medicare lines of business operations and PACE health plan operations, including coordination with and oversight of delegated health networks, contracted providers and contracted vendors.

Reviews and monitors Medicare programs and PACE program financial performance, provides recommendations and develops action plans.

Develops and monitors 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.

Oversees the development of strategic plans, work plans and other initiatives for the OneCare and PACE program health plan operations.

Oversees the coordination of data mining and data analysis activities for contracting and HCC improvement activities for applicable programs.

Partners 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.

Facilitates 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 and develops solutions to issues or problems

Collaborates 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.

5% - Completes other projects and duties as assigned.

Minimum Qualifications:

Bachelor's degree in business administration or related field PLUS 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; 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.

4 years of progressive leadership experience, including direct supervision of staff required.

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.

Required Licensure / Certifications:

n/a

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.

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 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, 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. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the alliantbenefits.cld.bz/25caloptimacabenguide regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

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 February 21, 2025 at 9:00 PM (PST). 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.

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

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 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 at 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.

To apply, please visit: apptrkr.com/6043878

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