NEOGOV · 1 week ago
Sr Manager, Operation and Business Configuration (Sr Manager I)
Orange, CA
Full-time
Hybrid
Mid, Senior Level
$121K/yr - $193K/yr
5+ years expCalOptima Health is the single largest health plan in Orange County, serving one in four residents. They are seeking a highly motivated Sr Manager, Operation and Business Configuration to lead claims analytical support, collaborate with leadership, and ensure compliance with business rules and government regulations.
GovTechHuman ResourcesInformation TechnologySoftware
Responsibilities
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
Provides an environment that engages staff to fully participate in the overall department functions and workload balancing strategies
Develops and implements corrective action plans and trains staff as needed
Establishes and manages teams to a set of standards and governance to improve performance and support effective development and outputs
Provides management oversight and direction to Data Analysts Business team and serves as a liaison with internal and external entities such as Clearinghouse and health networks to ensure claims and authorization data load integrity
Provides management oversight and direction to the Clearinghouse Data Analyst team for intake requirements, analysis, conducting clearinghouse user acceptance testing and identifies impacts to systems and processes
Tracks and trends teams performances by way of dashboards, monitoring day-to-day activities of each claim operational areas, claims operational vendors and all clearinghouses
Represents Claims department and participates in regulatory audit presentations and demonstrations and conducts follow up remediation action items from the audit as needed
Works collaboratively with the Office of Compliance, Information Technology (IT), claims vendors and internal business teams on regulatory changes impacting claims adjudication and data integrity
Manages all claims vendor contract or scope of work (SOW) renewals and takes the lead for any request for proposal projects
Participates in CalOptima Health's enterprise projects impacting claims or operational payments and procedures/policies
Conducts claims presentation to staff, senior level leadership and CalOptima Health network providers
Maintains quality goals and production level within the department by collaborating with Claims department leadership teams and ensures that performance goals are consistently met and/or exceeded
Anticipates future demands of initiatives, strategic plans and regulatory updates and design/implement solutions to meet these needs
Ensures compliance with applicable internal policies and procedures and external state and federal regulations for multiple product lines (Medi-Cal, Medicare, Commercial (Covered California) and Program of All-Inclusive Care for the Elderly (PACE). Ensures overall claims adjudication is in accordance with the California Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) health plan regulatory requirements and guidelines
Intakes and reviews All Plan Letters (APL), CMS bulletins and regulatory guidance; oversees the development, timely and accurate implementation and publication/posting of claims-related regulatory requirements and reporting
Serves as the primary point of contact to answer questions related to system configuration business rules, various claim adjudication issues and resolves complex claims or benefit adjudication issues for department staff as well as other internal customers; responsible for the identification and resolution of provider claim issues including support of provider education and customer service staff in communications back to providers
Reviews and maintains department policies and procedures, recommends changes for more efficient operations, drafts new policies and procedures for director's review, communicates changes and updates to staff when appropriate
Stays current with regulatory guidelines impacting essential functions and data requirements
Develops the claims data standards and deploys automation tools to obtain and process claims data from different sources. Constructs datasets to analyze, inform, identify trends and support stakeholder decision-making
Identifies claims transaction inconsistencies, as well as implementation of controls and changes to systems and policies that support claims adjudication, thereby minimizing incorrect claims payment
Manages activities/service requests with Facets configuration, IT and EDI teams to scope, prioritize, and implement requirement changes
Manages and intakes all program implementation impacting Facets and systems supporting the Claims, Grievance and Appeals Resolution Services (GARS)/Provider Dispute Resolution (PDR) and Customer Service operations
Completes other projects and duties as assigned
Qualification
Required
Bachelor's degree in health information management, business administration, health administration or related field PLUS 5 years of experience in information technology business experience implementing claims adjudication programs and projects in a health plan setting 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
5 years of management/leadership experience that manages claims operation from intake to output of the claims payment required
5 years of experience utilizing Microsoft technologies required
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
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
Benefits
Participation in the California Public Employees Retirement System (CalPERS)
Low-cost medical/vision/dental insurance options
Paid time off
Flexible scheduling during core business hours
Telework options for some positions
Wellness program featuring diverse activities
CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution
Access to 457(b) retirement plans with pre/post-tax contribution options
Company
NEOGOV
NEOGOV is the leading provider of workforce management software uniquely designed for the public sector, education, and public safety.
501-1000 employees
H1B Sponsorship
NEOGOV has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (13)
2024 (10)
2023 (10)
2022 (18)
2021 (14)
2020 (16)
Funding
Current Stage
Late StageTotal Funding
$700MKey Investors
Warburg Pincus
2025-07-28Secondary Market· $700M
2025-07-28Acquired
2021-06-02Private Equity
Leadership Team
Shane Evangelist
CEO
Brandon McDonald
Head Of Marketing
Recent News
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2025-10-31
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