CalOptima is a county organized health system that administers publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. With $3.2 billion in annual revenue, CalOptima serves nearly 800,000 members, delivering services through 14 health networks. For the past four years, CalOptima has been rated the top quality Medi-Cal plan in California, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Ratings 2018–2019.
The Clinical Auditor will conduct routine oversight, monitoring and auditing, of externally delegated functions to ensure compliance with state, federal, and accreditation standards.
Bachelor’s degree in Health Sciences, Public Health, Health Administration, Nursing or other related field; or equivalent combination of education and work experience required.
Minimum current, unrestricted LVN license to practice in the state of California is required, RN preferred.
Minimum 2 years of experience in utilization management or equivalent experience required.
At least 1 year of experience in a health care delivery system, including health plan, medical group, or hospital management preferred.
Valid California driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for work away from the primary office 25% of the time or more.
CalOptima’s Clinical Auditor must work to:
Work independently, while having excellent time management and organization skills. Applicant must also be able to prioritize, manage multiple tasks, and have strong attention to detail.
Organize and administer a complex project plan for the achievement of organizational and audit and oversight goals and objectives.
Demonstrate and motivate others in effective team coordination and cooperation.
Establish and maintain effective working relationships with all levels of staff, other programs, agencies and the public.
Assist in the formulation of policies and procedures; understand and interpret policies, procedures and regulations.
Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Services.
CalOptima’s Clinical Auditor must have the ability to:
Legislative, regulatory and utilization management and quality requirements for health care service delivery to beneficiaries of the following programs: Medi-Cal, Cal MediConnect, and Medicare.
Managed care compliance for Medi-Cal and Medicare.
Principles and techniques of project management to ensure that numerous goals, objectives and detailed actions are properly identified, and their status monitored.
Principles and practices of managed health care, health care systems, and medical administration.
Clinical criterial application/sources and utilization management processing of prior authorization requests, as well as retrospective and concurrent requests.
For a complete job description and to apply online, please go to www.caloptima.org. Questions can be directed to Debbie Neal, Senior Recruiter, 657-235-6891 or firstname.lastname@example.org.