Department(s): Quality Improvement
Reports to: Director II
FLSA status: Non-Exempt
Salary Grade: L - $77,000 - $127,094

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 on Monday, December 11, 2023 at 11:59 PM. 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.

About CalOptima Health

Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you’re looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health!

About the Position

The Program Manager (Quality Improvement) will provide oversight, coordination and staff support to the Quality Improvement (QI) department in the areas of National Committee for Quality Assurance (NCQA) Accreditation, as well as quality requirements for the Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS). The incumbent will lead CalOptima Health’s Health Plan and Health Equity accreditation efforts to ensure CalOptima Health achieves its renewal accreditation. Specifically, the incumbent will work to enhance and strengthen CalOptima Health’s quality infrastructure, including program, policy, contract compliance and statutory and regulatory obligations with NCQA, DHCS and CMS. The incumbent will require the ability to complete a variety of detailed analyses, including the impact of accreditation and policy changes from the NCQA, the State of California and the federal government, communicating these changes with QI leadership and affected areas. The incumbent will lead and manage projects and other assignments in the QI department, including those relating to the quality program, workplan and evaluation. The incumbent will interact with CalOptima Health’s leadership, state and federal regulatory agencies, as needed.

Duties & Responsibilities:

• 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.
• Leads CalOptima Health through the NCQA Health Plan and Health Equity accreditation process and renewals and provides leadership to all business areas to ensure standards are known and met.
• Leads and facilitates NCQA regulatory audits and audit readiness activities for QI department.
• Stays current on NCQA accreditation standards as well as local, state and federal health care environment; identifies issues and communicates areas that may impact CalOptima Health’s QI programs.
• Ensures all NCQA related policies are reviewed and updated, as needed, annually. Work directly with regulatory and compliance to ensure submissions are reviewed timely and with legal review.
• Engages and collaborates with all external NCQA and regulatory related vendors/organizations, including but not limited to NCQA and NCQA Consultants, to ensure standards are known and met and accreditation surveys are submitted accurately and timely.
• Initiates and maintains contact with key business owners to ensure proper submission of required documentation for the accreditation and renewal survey and regulatory audits.
• Designs and develops process improvements for the QI department to ensure annual QI program, workplan and evaluation is monitored and executed as planned.
• Represents QI at various CalOptima Health committee meetings such as the Quality Improvement Health Equity Committee (QIHEC) and its related subcommittees, as well as the Health Network Forum and the Joint Operation Meetings with health networks.
• Designs and develops process improvements for the QI department as the one-stop shop for regulatory information.
• Manages the accurate and timely submission of regulatory filings and reporting requirements on an ongoing basis.
• Works with all CalOptima Health departments in response to inquiries, problem-solving and promoting CalOptima Health’s mission and message.
• Researches national, state and local health policy issues that may impact CalOptima Health’s mission, vision and strategic goals.
• Leads and facilitates the NCQA Steering Committee Meeting.
• Represents QI department in various internal and external meetings.
• Provides QI program support to QI managers and other team members, assuring PQI, Credentialing, FSR and PARS processes are compliant with regulatory or audit and accreditation requirements.
• Completes other projects and duties as assigned.

Experience & Education:

• Bachelor’s degree in a Health Care or related field required.
• 3 years of experience working with health care delivery systems and/or in a public agency serving the related population or equivalent required.
• 3 years of experience successfully managing and achieving NCQA accreditation for a health plan or equivalent required.
• 2 years of experience within managed care and quality management or equivalent 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.

Preferred Qualifications:

• 2 years of experience with outreach and public speaking/public relations.

Physical Demands and Work Environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of job, employee may be required to move about the organization and to travel to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case while traveling, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting. Occasional travel to off-site locations is required.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.

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. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

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 employment 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 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.