Manager, Coding Quality
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 $3.6 billion in annual revenue, CalOptima serves nearly 800,000 members, delivering services through four programs, Medi-Cal, OneCare Connect, OneCare and PACE. For the past six 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 2019–2020.
The Manager, Coding Quality manages the coding team and the Claims department analytical support unit which consists of business analytics and process improvement. This position will be responsible for ensuring staff are trained and can effectively manage work volume based on regulatory requirements and contractual provision activities. The Manager is also responsible for the strategic and tactical implementation of CalOptima business rules and government regulations for all initiatives and projects that impacts the Claims department. Exercises direct supervision over assigned staff and works directly with the management team to identify system issues, recommend training needs and implement operational improvements.
Bachelor’s degree in a health care field or an equivalent combination of education and experience is required.
3 years supervisory experience strongly preferred.
5 years progressive healthcare operations management experience.
Claims, billing, encounter or coding experience strongly preferred.
CalOptima’s Manager, Coding Quality must possess the ability to:
Communicate effectively with levels and in situations requiring instructing, consulting and advising.
Assist in the formulation of policies and procedures; understand and interpret policies, procedures and regulations.
Manage a complex claims analytics support program to support government regulations.
Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the public.
Encourage the professional performance and development of subordinate staff.
Develop and maintain quality control methods.
Effectively utilize computer and appropriate software (i.e., Microsoft Office Suite, etc.).
Prepare clear, comprehensive written and oral reports and materials.
Analyze problems and find and implement solutions.
CalOptima’s Manager, Coding Quality must have the knowledge of:
Program development, management reporting and systems implementation.
Claims payment principles, policies and coding structure; i.e., ICD10, CPT and HCPCS.
Managed Care, Government Programs (Medicare, Medi-Cal & Commercial guidelines and regulations) in addition to coding guidelines.
Principles and practices of health care, health care systems, and medical administration; benefit interpretation and administration.
Benefit interpretation and administration.
Principles and techniques of effective management include training, monitoring, evaluation and reporting.
Principles and techniques of project management to ensure that numerous goals, objectives and detailed actions are properly identified, and their status
Knowledge and use of Medicare fee schedules, Diagnosis-Related Groups (DRGs), Stoploss, Medi-Cal and Medicare fee schedules and medical
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 email@example.comPosition Description »