Department(s): Quality Improvement (QI)
Reports to: Director, Quality Improvement
FLSA status: Exempt
Salary Grade: N - $95,000 - $155,078

Full Telework OpportunityThis position is a remote opportunity for Southern California Applicants. In order to be considered, you must live in Southern California or be willing to relocate.

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 the Position

The Manager of Quality Improvement (QI) (Credentialing) will oversee the day-to-day operations of the Credentialing team. The incumbent will develop, implement, and manage quality improvement programs and activities related to Provider Credentialing which is critical to ensure member care and safety at CalOptima Health. The incumbent will lead and monitor Provider Credentialing QI initiatives and projects to ensure all credentialing standards are met. The QI Manager will develop integrated and collaborative strategies with Provider Contracting, Provider Relations and Provider, Data, Management Systems to improve provider onboarding and effectively enhance the delivery of member care. The incumbent will conduct detailed analysis on Credentialing work processes to identify barriers to care and implement recommendations for improvement and determine effectiveness of interventions.

Duties & Responsibilities:

• 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 team responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the team.
• Oversees the credentialing functions to ensure requirements within policies and procedures, regulatory and accreditation standards are met.
• Hires, supervises, and trains the Credentialing team including conducting performance reviews and setting goals for the team and individual staff.
• Manages credentialing staff workload and ensure overtime and budget requirements are met.
• Interfaces with all provider-related departments to identify, implement and evaluate quality improvement for credentialing activities.
• Supports in analyzing barriers to the efficient and effective delivery of quality of care services through the provider network.
• Assists in maintaining a quality assurance process to ensure accuracy of the credentialing data and system.
• Supports the development of integrated strategies to increase the delivery of quality and access to care.
• Assists in developing and/or revising credentialing related policies and procedures annually.
• Provides support to Quality Improvement subcommittees, specifically Credentialing and Peer Review Committee and other committees working on quality improvement activities.
• Completes other projects and duties as assigned.

Experience & Education:

• Bachelor’s degree in Health Care Administration, Healthcare or related field required.
• 5 years professional credentialing experience in a managed health care organization required, preferably in a capitation model.
• 2 years of credentialing management experience required, preferably within healthcare.
• Extensive experience with credentialing, NCQA, DHCS, CMS, and other quality and regulatory standards 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:

• Master’s degree.
• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM).
• Experience working with a Credentialing Verification Organization (CVO).
• Significant experience within Managed Care and Quality Management.

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: Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee must be able to use hands and fingers, especially for typing on the computer and using the mouse. Employee must also be able to talk and hear, particularly for regular communication during meetings and on the phone.

• Work Environment: Office environment where employee must be able to tolerate moderate changes in office temperatures and noise levels.

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 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.

Required Skills

Required Experience