Training Program Coordinator
Job DescriptionWhy CalOptima?
CalOptima 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. Job Summary
Under general supervision, the Training Program Coordinator provides grievance and appeals specialized tasks relevant to an assigned program and/or projects. The incumbent requires the ability to design, develop and effectively deliver a training program for Grievance & Appeals (GARS) staff. The incumbent is responsible for auditing grievance and appeal activity performed with the Grievance & Appeals department following regulatory and internal guidelines in conjunction with CalOptima policies and procedures. The incumbent is responsible for reviewing quality assurance results and providing member and provider grievance and appeals training based on internal and external audit results. The Training Program Coordinator will provide general trend information to management. The incumbent must be able to provide assistance to the Compliance department for internal audits and Centers for Medicare & Medicaid Services (CMS), Department of Health Care Services (DHCS) or Department of Managed Health Care (DMHC) audits, as well as research and distribute updates based on regulatory guidelines. Position involves specialized background or knowledge regarding grievance, appeals, provider dispute resolution, authorization rules, claims processing and division of financial responsibility and, regulatory guidelines relevant to grievance and appeals. The incumbent will often work independently, perform complex research, and/or administrative responsibilities. Exercises discretion and judgment and may coordinate/supervise a function and the work of others within the program or representing the program/project.Position Responsibilities:
Possesses the Ability To:
- 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.
- Develops and maintains a comprehensive training program and conducts new hire training.
- Conducts training audits using CalOptima approved tools which are consistent with all regulatory, contractual and accrediting standards and requirements which may include:
- Analyzes and reviews case files to determine if the appropriate case classified was utilized based on regulatory guidelines.
- Develops reporting and trending for management.
- Analyzes and reviews case files to determine if cases were resolved within the required regulatory timeframe.
- Analyzes and reviews case files to determine if the case was handled appropriately based on regulatory and internal guidelines in conjunction with CalOptima policies and procedures.
- Analyzes and reviews grievance and appeal resolution letter(s) to determine if all member or provider complaints were identified and resolved appropriately.
- Analyzes and reviews grievance and appeal letters to ensure appeal language is appropriate to each line of business and complaint type was accurately utilized
- Audits all decisions that have been overturned to determine if they have been effectuated timely and accurately.
- Conducts oversight of the day-to-day grievance & appeals processes for new hires.
- Conducts training on changes to workflow(s) based on departmental updates and based on errors identified during internal and external audits.
- Determines on-going training needs as well as identify cross-training opportunities.
- Develops, updates and maintains desktop level procedures (desktops).
- Provides feedback (report card) to new staff on opportunities for improvement.
- Serves as a liaison between GARS, Office of Compliance, and Regulatory Affairs for regulatory updates, provides updates during weekly/monthly meetings and conducts trainings on the changes as needed.
- Compiles, summarizes and provides recommendations for improvement based on audit results to the upper management.
- Works closely with management to identify any training, system or workflow opportunities as related to member grievance and appeals and provider grievances, disputes and appeals.
- Completes other projects and duties as assigned.
Experience & Education:
- Handle multiple tasks and meet deadlines.
- Establish and maintain effective working relationships with CalOptima leadership and staff.
- Provide professional support to managers and staff.
- Identify issues and problems, develop solutions, and prepare recommendations, including training, desktop revisions, and procedures.
- Communicate clearly and concisely, both orally and in writing.
- Analyze data, identify pertinent information, prepare reports and provide recommendations to management.
- Work independently with minimal supervision.
- Influence others using a positive approach.
- Maintain quality and productivity standards as set by management.
- Plan, organize and prioritize work.
- Have project management skills, be well organized and detailed oriented.
- Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
- High School diploma or equivalent required.
- 2 years of health care management experience, preferably in managed care environment in related area of responsibility (i.e., customer service, member grievances and appeals and/or provider grievances and appeals) required.
- HMO, Medicare, Medi-Cal/Medicaid and health services 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.
- Bachelor's degree preferred.
- Experience in training in a managed care environment preferred.
- Experience in development and presentation of training tools and materials preferred.
- Both Medicare and Medi-Cal customer service and claims experience preferred.
- Bilingual in English and in one of CalOptima's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese) preferred.
- Grievance and appeals regulatory requirements for both member and provider.
- Medical terminology, CPT coding, HCPC, Revenue Codes, and ICD-10.
- Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling and proper word usage, grammar, punctuation, and sentence structure.
- Medicare and Medi-Cal requirements/regulations.
- Training methods and techniques for successful individual outcomes.
- Implementing programs or projects.
Grievance & Appeals (GARS)Reports to:
Manager, Grievance & AppealsFLSA status:
H - $29.37 - $40.72 ($59,000 - $84,7000)CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima 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 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. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/3916Copyright ©2022 Jobelephant.com Inc. All rights reserved.
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