Department(s): Quality Improvement
Reports to: Manager Quality Improvement
FLSA status: Non-Exempt
Salary Grade: C - $43,281 - $61,798

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 ****Tuesday, February 20, 2024 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 Assistant (Potential Quality Issues) will provide assistance with specialized tasks relevant to Potential Quality Issues (PQI) in support of the Quality Improvement (QI) Nurses and Medical Directors.

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.
• Receives and processes clinical PQI files for QI Nurse Specialist in the electronic system.
• Requests medical records or clinical responses from health networks, physician medical groups and providers.
• Obtains and files copies of medical records in the electronic system.
• Documents and logs PQI information in the electronic system.
• Collects data, identifies pertinent information and prepares files for review by the QI Nurse Specialist and Medical Director.
• Generates and mails appropriate written correspondence to providers, members and health networks.
• Contacts members, health networks or providers to get additional information or coordinate care.
• Prepares PQI files for the Credentialing and Peer Review Committee (CPRC) and sends files electronically to the appropriate Medical Director.
• Prepares and submits files for external review and retrieves files once the review is completed.
• Assists with communication status of activities with the nurses, Medical Directors, leadership, CalOptima Health departments and health networks.
• Represents PQI on projects or acts as a liaison within or outside CalOptima Health.
• Completes other projects and duties as assigned.

Experience & Education:

• High School diploma or equivalent required.
• 1 year of experience in working with provider offices or hospitals requesting medical records in a managed care-health plan or a medical group required.
• 1 year of experience in administrative support 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.

Preferred Qualifications:

• Experience in PQI.
• Experience working in a medical setting, such as a doctor’s office, hospital or urgent care.

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. 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, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting.

• § 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.

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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.

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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.

Required Skills

Required Experience

Minimum Education

High School diploma or GED equivalent.