Sr Manager, Quality and Compliance (PACE) (Sr Manager II)

Sr Manager, Quality and Compliance (PACE) (Sr Manager II)

CalOptima

CalOptima Health is seeking a highly motivated an experienced Sr. Manager, Quality and Compliance (PACE) (Sr Manager II) to join our team. The Sr Manager II for Quality and Compliance will develop, integrate, review, update and implement quality and compliance and training programs for CalOptima Health's Program of All Inclusive Care for the Elderly (PACE) to comply with regulatory, contractual and board requirements. The incumbent will manage the PACE health plan's clinical grievance and appeals review process which includes investigation of all quality reviews for potential quality of care concerns and quality of service and access issues, as well as collection and analysis of appropriate data in accordance with applicable state and federal regulations, compliance standards and policies and procedures.

Position Information:

• Department: PACE - Administrative
• Salary Grade: 317 - $132,969 - $212,751 ($63.93 - $102.2841)
• Work Arrangement: Partial 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 and evaluates staff; reviews and sets goals for the department and staff.
  • Acts as a liaison between PACE program leadership and CalOptima Health's Compliance department for quality-related issues. Creates and implements corrective action plans (CAPs) as required and requested by the Compliance department.
  • Oversees potential quality incident reporting's from external specialty contractors or internal contracting entities in collaboration with the PACE Medical Director.
  • Oversees the Medical Records and Scheduling departments to ensure that PACE is meeting regulatory requirements and timelines for participant care.
  • Oversees the scheduling department and conducts analysis to ensure the participants are having adequate access and timely scheduling of outside appointments.
  • Plans, develops and oversees training on Quality Assurance & Performance Improvement (QAPI) activities and techniques and competency testing for PACE staff, as required.
  • Recommends the selection of specific topics for review in support of quality improvement.
  • Leads the Participant Rights training annually.
  • Oversees compliance, training and reporting as it pertains to the Medicare Part D program.
  • Attends and supports the Quality Assurance committee of the CalOptima Health Board of Directors on PACE-related matters.
  • Represents the PACE program within applicable QI committees, alongside the PACE Director and Medical Director. - (Essential)

• 45% - Program Oversight
  • Conducts an annual review of the Quality Improvement (QI) program for PACE and updates plans as appropriate.
  • Prepares routine and special reports of QI activities and performance to regulatory bodies as required under state and federal laws and regulations, including unusual incidences and sentinel event reporting.
  • Conducts the ongoing analysis and assessment of operational performance for continuous process improvements, efficiencies and participant satisfaction.
  • Coordinates the development and implementation of program-wide and center-specific quality indicators; ensures that these are in line with national and state PACE benchmarking tools.
  • Tracks, trends and analyzes data for QI activities including coordinating the collection, entry and assessment of data; utilizes findings and trends to improve policies and procedures and processes.
  • Oversees investigation, fact-gathering and follow-up for participant and/or caregiver grievances and appeals related to program services; prepares quarterly reports on grievances and appeals to PACE leadership.
  • Conducts ongoing analysis and assessment of specialty care access and makes recommendations to the PACE leadership team.
  • Conducts ongoing assessments of Medical Records team to ensure PACE is receiving medical records in a timely manner to support patent care and treatment compliance.
  • Ensures that Medical Records and Scheduling departments are closing the loop from start to finish.
  • Assists in the interface between consumers and program leadership for quality-related grievances and appeals.
  • Leads effort to participate, organize and prepare PACE staff for regulatory audits as well as frequently audits the participant's medical records and educates the team on proper maintenance.
  • Compiles statistical data and writes narrative reports and presentations that summarize quality assurance findings and recommendations to PACE and CalOptima Health's leadership.
  • Coordinates with national initiatives in PACE quality management, including the development of an accreditation program, the Centers for Medicare & Medicaid Services (CMS) Continuous Quality Improvement (CQI) program, National PACE Association (NPA) quality initiatives and provides technical assistance for developing sites.
  • Coordinates with PACE network providers to obtain relevant information in support of CalOptima Health's PACE QI activities and requirements.
    
    
• 5% - Completes other projects and duties as assigned.

Minimum Qualifications:

• Bachelor's degree in health care administration, health services, public health, business administration, nursing or related field PLUS 5 years of professional CMS, NPA, CQI or other quality and/or regulatory experience in a managed health care organization 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.
  
• 3 years of progressive leadership experience, including direct supervision of staff, in a health care QI and compliance capacity required.
  
• Professional experience in quality management, specifically with statistical packages and analysis, including presenting findings required.

Preferred Qualifications:

• Master's degree in health care administration, health services, public health, business administration, nursing or related field.

Required Licensure / Certifications:

• Current unrestricted Registered Nurse (RN) license to practice in the state of California.

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, 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 18, 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.


To apply, please visit: https://jobs.caloptima.org/jobs/sr-manager-quality-and-compliance-pace-sr-manager-ii-pace-garden-grove-california-united-states







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