Sr Manager, Operation and Business Configuration (Sr Manager I)

Sr Manager, Operation and Business Configuration (Sr Manager I)

CalOptima

CalOptima Health is seeking a highly motivated Sr Manager, Operation and Business Configuration (Sr Manager I) to join our team. The Sr Manager I for Operation and Business Configuration will function as a primary point of contact for the claims analytical support unit which consists of data analytics, process improvement and claims clearinghouse vendor oversight. The incumbent will collaborate with leadership on the development and implementation of analytical tools to identify department trends and will manage dedicated resources for the day-to-day operations to carry out the strategic and tactical execution of CalOptima Health business operations, ensuring compliance with business rules and government regulations.

Position Information:

• Department: Claims Administration
• Salary Grade: 316 - $120,881 - $193,410 ($58.12 - $92.9856)
• Work Arrangement: Partial Telework
  
  **This position is eligible for telework in California.**

Duties & Responsibilities:

• 40% - 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, manages, trains, reviews and sets goals for the department and staff.
  • Provides an environment that engages staff to fully participate in the overall department functions and workload balancing strategies.
  • Develops and implements corrective action plans and trains staff as needed.
  • Establishes and manages teams to a set of standards and governance to improve performance and support effective development and outputs.
  • Provides management oversight and direction to Data Analysts Business team and serves as a liaison with internal and external entities such as Clearinghouse and health networks to ensure claims and authorization data load integrity.
  • Provides management oversight and direction to the Clearinghouse Data Analyst team for intake requirements, analysis, conducting clearinghouse user acceptance testing and identifies impacts to systems and processes.
  • Tracks and trends teams performances by way of dashboards, monitoring day-to-day activities of each claim operational areas, claims operational vendors and all clearinghouses.
  • Represents Claims department and participates in regulatory audit presentations and demonstrations and conducts follow up remediation action items from the audit as needed.
  • Works collaboratively with the Office of Compliance, Information Technology (IT), claims vendors and internal business teams on regulatory changes impacting claims adjudication and data integrity.
  • Manages all claims vendor contract or scope of work (SOW) renewals and takes the lead for any request for proposal projects.
  • Participates in CalOptima Health's enterprise projects impacting claims or operational payments and procedures/policies.
  • Conducts claims presentation to staff, senior level leadership and CalOptima Health network providers.
  • Maintains quality goals and production level within the department by collaborating with Claims department leadership teams and ensures that performance goals are consistently met and/or exceeded.
  • Anticipates future demands of initiatives, strategic plans and regulatory updates and design/implement solutions to meet these needs.
    
    
• 35% - Program Oversight
  • Ensures compliance with applicable internal policies and procedures and external state and federal regulations for multiple product lines (Medi-Cal, Medicare, Commercial (Covered California) and Program of All-Inclusive Care for the Elderly (PACE). Ensures overall claims adjudication is in accordance with the California Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) health plan regulatory requirements and guidelines.
  • Intakes and reviews All Plan Letters (APL), CMS bulletins and regulatory guidance; oversees the development, timely and accurate implementation and publication/posting of claims-related regulatory requirements and reporting.
  • Serves as the primary point of contact to answer questions related to system configuration business rules, various claim adjudication issues and resolves complex claims or benefit adjudication issues for department staff as well as other internal customers; responsible for the identification and resolution of provider claim issues including support of provider education and customer service staff in communications back to providers.
  • Reviews and maintains department policies and procedures, recommends changes for more efficient operations, drafts new policies and procedures for director's review, communicates changes and updates to staff when appropriate.
  • Stays current with regulatory guidelines impacting essential functions and data requirements.
    
    
• 20% - Technical Operations
  • Develops the claims data standards and deploys automation tools to obtain and process claims data from different sources. Constructs datasets to analyze, inform, identify trends and support stakeholder decision-making.
  • Identifies claims transaction inconsistencies, as well as implementation of controls and changes to systems and policies that support claims adjudication, thereby minimizing incorrect claims payment.
  • Manages activities/service requests with Facets configuration, IT and EDI teams to scope, prioritize, and implement requirement changes.
  • Manages and intakes all program implementation impacting Facets and systems supporting the Claims, Grievance and Appeals Resolution Services (GARS)/Provider Dispute Resolution (PDR) and Customer Service operations.
    
    
• 5% - Other
  • Completes other projects and duties as assigned.

Minimum Qualifications:

• Bachelor's degree in health information management, business administration, health administration or related field PLUS 5 years of experience in information technology business experience implementing claims adjudication programs and projects in a health plan setting 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.
  
• 5 years of management/leadership experience that manages claims operation from intake to output of the claims payment required.
  
• 5 years of experience utilizing Microsoft technologies required.

Preferred Qualifications:

• N/A

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 2025 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 July 22, 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 (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/sr-manager-operation-and-business-configuration-sr-manager-i-505-city-parkway-west-california-united-states







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