DEPARTMENT(S): Regulatory Affairs & Compliance (Medicare) REPORTS TO: Manager, Regulatory Affairs & Compliance (Medicare) FLSA STATUS: Non-Exempt SALARY GRADE:  L - $37.0192 - $52.4038 ($77,000 - $109,000)

JOB SUMMARY

The Program Manager (Medicare) coordinates and maintains CalOptima’s relationships with regulatory agencies such as the Centers for Medicare & Medicaid Services (CMS) and the Department of Healthcare Services (DHCS). The incumbent requires the ability to complete a variety of detailed analyses, including the assessment of the impact of state and federal regulatory changes on CalOptima’s Medicare programs. The incumbent manages projects and other assignments in the Regulatory Affairs & Compliance (Medicare) department, including those relating to department efficiency to ensure department objectives and initiatives are met. The incumbent will interact with CalOptima’s executives and department management, legal counsel, and State and Federal regulatory agencies. The incumbent also supports other CalOptima staff on related projects.

POSITION RESPONSIBILITIES:

• Assists in the management of CalOptima’s daily relationship with the DHCS and the CMS for CalOptima’s Medicare and Medi-Cal programs.
• Analyzes, interprets, and makes recommendations regarding the regulatory implications of changes to statutes, regulations, sub-regulatory guidance, and contracts.
• Supports and facilitates the bid development and submission process for CalOptima’s Medicare programs.
• Leads and facilitates regulatory audits and audit readiness activities.
• Manages the submission of regulatory filings and reporting requirements on an ongoing basis.
• Manages the process for the issuance, development, remediation, and validation of corrective action plans (CAPs) for identified and/or reported issues of non-compliance.
• Partners with other departments in the development of annual member materials for the Medicare programs (e.g., Evidence of Coverage, Summary of Benefits, Provider Directories).
• Assists in the preparation of updates and reports to CalOptima’s management, Board of Directors, and Compliance Committee related to regulatory affairs and compliance activities.
• Works with all CalOptima departments in response to inquiries, problem-solving, and promoting CalOptima’s mission and message.
• Assists in the review, revision, development, and implementation of policies and process improvements for the Regulatory Affairs & Compliance (Medicare) department.
• Keeps current on the local, state, and federal regulatory environment to identify issues that may impact CalOptima’s programs.
• Represents CalOptima at various internal and external meetings.
• Other projects and duties as assigned.

POSSESSES THE ABILITY TO:

• Organize and administer a complex project plan for the achievement of regulatory goals and objectives.
• Build strong regulatory relationships at the state and federal level.
• Communicate clearly and concisely, both verbally and in writing, with all levels of staff, other agencies, and stakeholders.
• Have exceptional initiative and follow-through on projects with minimal supervision or guidance.
• Translate complex concepts into clear messages.
• Demonstrate and motivate others in effective team coordination and cooperation.
• Establish and maintain effective working relationships with CalOptima leadership, staff, and regulatory agencies.
• Assist in the formulation and interpretation of policies, procedures, and regulations.
• 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.”

EXPERIENCE & EDUCATION:

• Bachelor’s degree in Healthcare Administration or related field, or equivalent work experience in healthcare required.
• 3 years of experience in government and/or healthcare, interacting with governmental requirements and regulations is required.

TRAVEL:

• Have access to an approved means of transportation for work away from the primary office approximately 5% of the time.

PREFERRED QUALIFICATIONS:

• Master’s degree in a Healthcare Administration or related field preferred.
• Experience working with Managed Care organizations including health plans such as Medicare Advantage, Medicare Part D, Special Needs Plans (SNPs), Medicare-Medicaid Plans (MMPs) / Cal MediConnect, and/or a Program of All-Inclusive Care for the Elderly (PACE) strongly preferred.

KNOWLEDGE OF:

• Regulatory requirements related to Medicare Advantage, Medicare Part D, MMPs / Cal MediConnect, and PACE.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima 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 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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Required Skills Required Experience