Program Manager (Medicare)

Program Manager (Medicare)

CalOptima

CalOptima Health is seeking a highly motivated an experienced Program Manager (Medicare) to join our team. The Program Manager (Medicare) will be responsible for the coordination and maintenance of CalOptima Health's relationships with regulatory agencies such as the Centers for Medicare & Medicaid Services (CMS) and the Department of Healthcare Services (DHCS). The incumbent will manage projects and other assignments in the Regulatory Affairs & Compliance (Medicare) department, including those relating to department efficiency to ensure department objectives and initiatives are met. The incumbent will complete a variety of detailed analyses, including the assessment of the impact of state and federal regulatory changes on CalOptima Health's Medicare programs. The incumbent will interact with CalOptima Health's leadership, legal counsel, and state and federal regulatory agencies. The incumbent will support other CalOptima Health staff on related projects.

Position Information:

Department: OOC - Medicare Regulatory Affairs & Compliance

Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947)

Work Arrangement: Full Telework with occasional in-office meetings

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

Duties & Responsibilities:

60% - Program Support

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 management of CalOptima Health's daily relationship with DHCS and CMS for CalOptima Health's Medicare and Medi-Cal programs.

Analyzes, interprets and makes recommendations regarding the regulatory implications of changes to statutes, regulations, sub-regulatory guidance and contracts.

Supports and facilitates the bid development and submission process for CalOptima Health's Medicare programs.

Leads and facilitates regulatory audits and audit readiness activities, including, but not limited to, Medicare Data Validation (MDVA), Timeliness Monitoring Project (TMP), annual readiness checklist validation, CMS program audits and CMS/DHCS Program of All-Inclusive Care for the Elderly (PACE) program audits.

Manages the submission of regulatory filings and reporting requirements on an ongoing basis.

Manages the process for the issuance, development, remediation and validation of corrective action plans (CAPs) for identified and/or reported issues of non-compliance related to CalOptima Health's Medicare programs, whether from regulatory audit findings or compliance investigations.

35% - Administrative Support

Partners with other departments in the development of annual member materials for Medicare programs (e.g., Evidence of Coverage, Summary of Benefits, Provider Directories).

Assists in the preparation of updates and reports to CalOptima Health's leadership, Board of Directors and Compliance Committee related to regulatory affairs and compliance activities.

Works with all internal departments in response to inquiries, problem-solving and promoting CalOptima Health's mission and message.

Assists in the review, revision, development, and implementation of policies and process improvements for the Regulatory Affairs & Compliance (Medicare) department.

Keeps current on the local, state and federal regulatory environment to identify issues that may impact CalOptima Health's programs.

Represents CalOptima Health at various internal and external meetings.

5% - Completes other projects and duties as assigned.

Minimum Qualifications:

Bachelor's degree in health care administration or related field PLUS 3 years of experience in government and/or health care, interacting with governmental requirements and regulations is 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.

Have access to an approved means of transportation for work away from the primary office approximately 5% of the time.

Preferred Qualifications:

Master's degree in health care administration or related field.

Experience working with Managed Care organizations including health plans such as Medicare Advantage, Medicare Part D, D-SNPs and/or a PACE.

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 April 23, 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/6132542

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