Program Specialist

CalOptima
505 City Pkwy W, Orange, California 92868 United States  View Map
Posted: Sep 13, 2024
  • Salary: 305 - $55,966 - $83,949 ($26.91 - $40.3601) USD
  • Full Time
  • Human and Social Services
  • Public Health
  • Job Description

    4005021.gif

    Program Specialist

    CalOptima


    CalOptima Health is seeking a highly motivated an experienced Program Specialist to join our team. The Program Specialist will provide administrative clinical support services to the Grievance and Appeals Nurse Specialists in the investigation and preparation of cases for review based on clinical information, benefits, applicable regulations related to member or provider dispute of decisions. The incumbent will collect additional medical information from CalOptima Health members, and/or providers to complete appeal case reviews. The incumbent will support the department with the external medical review request process as it relates to appeals.

    Position Information:
    • Department: Grievance & Appeals
    • Salary Grade: 305 - $55,966 - $83,949 ($26.91 - $40.3601)
    • Work Arrangement: Full Office

    Duties & Responsibilities:
    • 85% - Program Support
      • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
      • Assists with case pre-analysis and procures appropriate medical records and supporting documentation prior to sending appeal to internal stakeholders for case review.
      • Supports the external medical review request process as it relates to appeals.
      • Maintains departmental database and records' integrity by accurately entering case actions to assigned cases.
      • Works with internal and external departments to gather additional information such as claims copies, referrals, authorization or resolution and other related procedures.
      • Assists with State Fair Hearing preparation.
      • Assists with the notification process to members or providers on the clinical decision issued.
      • Works with Grievance and Appeals Nurse Specialists and Medical Directors, who oversee clinical aspects of the business, to ensure that the clinical issues are appropriately evaluated.

    • 10% - Administrative Support
      • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
      • Participates in departmental meetings, trainings and audits as needed.

    • 5% - Completes other projects and duties as assigned.

    Minimum Qualifications:
    • High School diploma or equivalent required PLUS 3 years of clinical experience required, preferably in a managed care environment; 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.
    • 1 year of experience with Medi-Cal, Healthy Families and Medicare reporting requirements including data validation audits required.

    Preferred Qualifications:
    • Certified Medical Assistant (CMA).
    • Bilingual in English and in one of CalOptima's defined threshold language (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).

    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, 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. 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 2024 CalOptima Health Benefits Guide 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 September 25, 2024 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 (714) 246-8400 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: https://jobs.caloptima.org/jobs/program-specialist-505-city-parkway-west-california-united-states






    img.php?id=5630203&image=logo
    Copyright 2024 Jobelephant.com Inc. All rights reserved.

    Posted by the FREE value-added recruitment advertising agency


    jeid-c852a5c07b64f641a76cf45eefa5869e
  • ABOUT THE COMPANY

    • CalOptima
    • CalOptima

    Our motto and programs

    “Better. Together.” is our motto, and it means that by working together, we can make things better — for our members and community. As a public agency, CalOptima was founded by the community as a County Organized Health System that offers health insurance programs for low-income children, adults, seniors and people with disabilities. As Orange County’s single largest health insurer, we provide coverage through four major programs:

     

    Medi-Cal

    California’s Medicaid Program for low-income children, adults, seniors and people with disabilities, offering comprehensive health care coverage

     

    OneCare Connect Cal MediConnect Plan

    Medicare-Medicaid Plan that combines Medicare and Medi-Cal benefits and adds worldwide emergency care, dental care, vision care and transportation to medical services at no extra cost

     

    OneCare (HMO SNP)

    Medicare Advantage Special Needs Plan for seniors and people with disabilities who qualify for both Medicare and Medi-Cal

     

    Program of All-Inclusive Care for the Elderly

    PACE for frail older adults, providing a full range of health and social services so seniors can remain living in the community

    Show more

MORE JOBS

  • Fire Plans Examiner

    • Long Beach, California
    • California State University (CSU) Chancellor's Office
    • Jul 14, 2024
    • Code Enforcement and Inspections
    • Fire and EMS
  • PEST CONTROL WORKER

    • Los Angeles, California
    • LOS ANGELES COUNTY
    • Jul 14, 2024
    • Variable Shift
    • Animal Control or Services
  • Corrections Nurse

    • Jail, Oregon
    • Deschutes County
    • Jul 14, 2024
    • Full Time
    • CORRECTIONS
    • Public Health
  • MANAGEMENT ASSISTANT

    • Long Beach, California
    • City of Long Beach, CA
    • Aug 21, 2024
    • Full Time
    • Clerical and Administrative Support
  • Engineering Technician IV (Department of Public Works)

    • San Bernardino, California
    • SAN BERNARDINO COUNTY, CA
    • Jul 14, 2024
    • Full Time
    • Engineering
    • Public Works
  • Eligibility Supervisor

    • Orange, California
    • Orange County, CA
    • Jul 14, 2024
    • Full Time
    • Administrative Analysis and Research
    • Clerical and Administrative Support
Show More
Apply Now Please mention you found this employment opportunity on the CareersInGovernment.com Job Board.
Please mention you found this employment opportunity on the CareersInGovernment.com Job Board.