Job Summary:

The Director is responsible for the development and expansion of CalOptima Direct (COD), and CalOptima Care Network (CCN). The Director will lead implementation efforts for initiatives that will

impact COD and CCN network operations. The Director will coordinate organizational efforts with internal and external stakeholders including COD members, providers and community based organizations.

The Director is responsible for all aspects of planning, organizing, directing and overseeing the of the COD and CCN operations. The Director is responsible for the strategic planning and financial performance of the plan necessary to implement the program’s objectives. Knowledge of and attention to the following program operational elements: program development and strategic business planning, operating systems, policies and procedures, quality and quality measurement, customer service, provider relationships and provider contracting, sales and marketing, and internal communication and consensus-building. The Director must have a comprehensive knowledge of the needs of Medi-Cal, Medicare and Dual Eligible beneficiaries, including an understanding of other medical and social programs that may be accessed by COD and CCN members.

Position Responsibilities:

  • Coordinate program activities and collaborate with other CalOptima departments, senior management and the health plans to assure proper operations of the COD and CCN program.
  • Coordinate the development of policies, procedures and standards for all department activities.
  • Maintain integrity, stability and overall financial stability of the COD and CCN provider networks.
  • Develop and foster effective collaboration between internal operating departments, as well as collaboration with external stakeholders, including members, providers and other entities.
  • Provide leadership, coordination and support to ensure effective communication, development and implementation of day-to-day operations of COD and CCN network, in a cross-functional capacity.
  • Define COD and CCN operational activities, policies and procedures, allocation of resources and assessment of staff performance.
  • Collaborates with Provider Relations, Contracting and other operational departments to maintain the integrity, stability and overall satisfaction in the provider network including hospitals, physicians, ancillary provider and other integrated delivery systems.
  • Collaborates with Medical Management and Clinical departments to ensure coordination of medical services and operational activities to ensure quality of care and member satisfaction of COD and CCN members.
  • Develops, recommends and collaborates with the Contracting Department in the implementation of provider reimbursement strategies and contracting models to meet strategic initiatives and financial performance.
  • Ensures compliance with requirements of contracts with the federal Centers for Medicare & Medicaid Services (CMS), State Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC) and CalOptima’s contracted providers.
  • Maintain compliance with laws, regulations and guidelines governing public health care and public agencies.
  • Communicate key information and messages to internal and external stakeholders related to the COD network, such as plan objectives and key measurements, quality improvement efforts and member focused services.
  • Interact with regulatory agencies, contractors, associations and stakeholders.
  • Provide direction, support and guidance to assigned staff.
  • Other projects and duties as assigned.