Manager, Clinical Operations - Grievance and Appeals Resolution Services

Manager, Clinical Operations - Grievance and Appeals Resolution Services

CalOptima

CalOptima Health is seeking a highly motivated an experienced Manager, Clinical Operations - Grievance and Appeals Resolution Services to join our team. The Manager Clinic Operations for Grievance & Appeals Resolution Services (GARS) will be responsible for the daily operations of GARS and managing the Nurse Specialist staff. The incumbent will be responsible for staying up to date on the latest information about CalOptima Health's member benefits and regulatory changes. The incumbent will ensure adherence to established policies and procedures regarding the appeals and grievance process and will provide training and guidance to the staff as needed. The incumbent will be a resource to the Nurse Specialist staff, Medical Directors and GARS management team as it relates to clinical issues that may arise.

Position Information:

• Department: Grievance & Appeals
• 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:

• 50% - Leadership
  • 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.
  • Manages day-to-day activities of the Nurse Specialist team.
  • Supervises and manages the performance development of the Nurse Specialist team to ensure compliance with regulatory requirements, accreditation standards and CalOptima Health's policies.
  • Interviews, onboards, trains, manages, motivates, supports and evaluates staff.
  • Monitors team performance and trends; provides coaching to staff to ensure adherence to policies and procedures and maintain the highest level of customer service.
  • Provides assistance in the development and implementation of policies and procedures, as well as providing orientation and ongoing training of Nurse Specialist staff.
    
    
• 45% - Program Oversight
  • Maintains knowledge of current regulatory requirements and industry trends.
  • Handles escalated member or provider cases/calls.
  • Responsible for prompt communication with staff.
  • Schedules monthly unit meetings to go over any changes to programs or training issues; schedules regular one-on-one meetings with staff to go over their monthly progress regarding their success.
  • Plans work for staff and determines staff priorities; sets or recommends work performance standards.
  • Reviews work procedures and recommends or changes procedures to be more time/cost efficient.
  • Assists with audits, assessment activities and other process improvement strategies to enhance the effectiveness of the GARS department.
  • Serves as a resource to departmental staff, internal departments and affiliated health networks regarding grievance and appeals.
  • Conducts presentations to internal or external customers.
    
    
• 5% - Completes other projects and duties as assigned.

Minimum Qualifications:

• Bachelor's degree in healthcare administration, nursing, or related field required PLUS 3 years of managed care experience, preferably in grievances and appeals 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.
  
• Current unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license to practice in the state of California is required.
  
• 3 years of supervisory/management experience in managed care required.
  

Preferred Qualifications:

• Unrestricted Registered Nurse licensed to practice in the state of California.

Required Licensure / Certifications:

• Current unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license to practice in the state of California is required.

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 August 28, 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/manager-clinical-operations-grievance-and-appeals-resolution-services-505-city-parkway-west-california-united-states







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