Department(s): Contracting
Reports to: Manager Contracting
FLSA status: Non-Exempt
Salary Grade: K - $70,000 - $114,268

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 ** Friday, February 9, 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 Contracts Specialist Sr will monitor policy updates to ensure compliance with operational and Centers for Medicare and Medicaid Services (CMS) and Department of Healthcare Services (DHCS) regulatory requirements and complete all required documentation. The incumbent will obtain the necessary approval from Regulatory Affairs Compliance (RAC) and coordinate the implementation, including ongoing monitoring, of such requirements, into the Contracting department’s daily operations/tasks. The incumbent will interpret DHCS All Plan Letters (APLs) and recommend appropriate actions to the Contracting leadership for implementation into the Contracting department’s policies, procedures and various programs and/or provider template agreements. The incumbent will also interface directly with a variety of provider types, including individual physicians, physician groups and hospital and ancillary providers. The incumbent will work with many departments and all levels of CalOptima Health’s leadership and staff to support policy, process and contracting related needs.

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.
• Interacts with staff and leadership to analyze, identify and make recommendations to policies and procedures that impact the Contracting department’s accountabilities and responsibilities.
• Serves as project lead to manage, coordinate and implement regulatory requirements whereby the department is primary or secondary.
• Tracks, analyzes and reports on legislative updates, including maintaining a department tracking log and submitting required information to the regulatory compliance department.
• Leads and monitors multiple small to medium sized projects under tight timelines simultaneously.
• Collaborates closely with the Contracting leadership on multiple department projects and keeps leadership abreast on progress, issues and status of new contracts, policies and regulatory requirements.
• Prepares summaries and detailed reports regarding contracted provider network(s) and assigned projects as needed.
• Responds appropriately to contracted provider complex inquiries and coordinates resolution with appropriate departments including facilitating warm hand offs.
• Acts as a contracting liaison between the provider and CalOptima Health.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Describe CalOptima Health’s model as a County Organized Health System (COHS) Medi-Cal and government program provider.
• Understand contract language, rate schedules and program policy and procedures.
• Follow CalOptima Health’s policies and procedures.
• Perform assigned functional activities and have exceptional initiative and follow-through on projects under general supervision or guidance.
• Adapt to constantly changing priorities in managing various projects simultaneously.
• Demonstrate strong organizational, problem solving and project management skills.
• Plan and facilitate meetings as needed and prioritize tasks to meet challenging deadlines.
• Establish and maintain effective working relationships with CalOptima Health’s leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

Experience & Education:

• Associate’s degree required.
• 4 years of experience in the health care field interacting with members, physicians, medical groups or health plans, overseeing administrative updates, data analytics or provider relations activities 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:

• Managed care contracting, provider relations or data analytics experience.
• Project leader experience.
• Network operations experience managing provider claims, capitation, network expansion or development.

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.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Off-site locations are equivalent to a typical physician office, hospital or other ancillary provider.

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

• Understand and apply adult learning theories
• Understanding of transitioning Service member populations
• Experience using Microsoft Office suite of tools
• Strong customer management and support skills
• Experience delivering interactive workshops and training to live audiences