Manager, Audit & Oversight (Coding)

CalOptima Health is seeking a highly motivated an experienced Manager Audit & Oversight to join our team. The Manager Audit & Oversight (Coding) will be responsible for program management and overseeing the operations of the department, including Medicare Hierarchical Condition Category (HCC) coding, Medi-Cal Chronic Illness and Disability Payment System (CDPS) coding, medical chart retrieval and chart review. The incumbent will provide support and direction to various departments within CalOptima Health to ensure compliance with the Centers for Medicare and Medicaid Services (CMS) regulatory requirements. The incumbent will maintain a leadership role for program audits including risk adjustment data validation (RADV), Office of Inspector General (OIG) and other audits as necessary to ensure coding integrity. The incumbent will interact with all levels of CalOptima Health staff, providers, health networks and stakeholders including the public, CMS staff, state and federal regulators, vendors and representatives of other agencies as needed.

Position Information

• Department: Financial Analysis
• Salary Grade: 316 - $120,881 - $193,410 ($58.12 - $92.9856)
• Work Arrangement: Full Telework
• This position is eligible for telework in California.**
  
  

Duties & Responsibilities

• 50% - Leadership Functions
• 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.
• Hires, manages, trains, reviews and sets goals for the department and staff.
• Executes strategic work plans and other initiatives for CalOptima Health Medicare and Medi-Cal programs as they relate to clinical documentation audit and coding integrity.
• Manages and/or coordinates staff throughout the organization in the implementation of strategic work plans or other initiatives for CalOptima Health Financial Analysis Audit and Coding program operations.
• Develops and reviews audit and coding program policies and procedures in collaboration with the CalOptima Regulatory Affairs department and recommends approval to CalOptima Health executive management and the CalOptima Health Board of Directors.
• Develops, reviews and recommends approval of clinical documentation audit and coding program policies and procedures to CalOptima Health executive management.
• Develops, reviews, defines and recommends approval of strategies for clinical documentation audit and coding program management to CalOptima Health executive management.
• Identifies problem areas, develops solutions to issues or problems, conducts strategic audits and ensures that all departments are adhering to the short and long-term objectives of coding related programs.
• 45% - Program Support
• Coordinates clinical documentation audit and coding integrity operations associated with Medicare and Medi-Cal lines of business.
• Collaborates with staff from across the organization to research specific issues as necessary to develop and analyze solutions and make policy or programmatic recommendations to address operational audit and coding issues.
• Ensures appropriate communication about CalOptima Health’s audit and coding operational issues and ensures adherence to work plans.
• Represents CalOptima Health audit and coding program operations at internal, community, state, federal and other meetings as required.
• Collaborates with CalOptima Health’s Regulatory Affairs department to implement Medicare and Medi-Cal audit and coding integrity program changes and communicates the request to stakeholders and project management to implement the changes.
• 5% - Completes other projects and duties as assigned.
  

Minimum Qualifications

• Bachelor’s degree in a relevant area, such as health care administration PLUS 4 years of experience in Medicare managed care and leading clinical documentation, audit and coding integrity staff 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.
• 4 years of experience working with health care delivery systems and/or in a public agency serving related populations required.
• 4 years of experience in a leadership position of a health plan required; leadership of a department or division is preferred.
  
  

Preferred Qualifications

• n/a
  
  

Required Licensure / Certifications

• Certified Coding Specialist (CCS), Certified Professional Coder (CPC) or Certified Professional Compliance Officer (CPCO).
  
  

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 {GenericListType_lifting}
  
  

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, 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 2025 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 February 20, 2025 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.