Lead the design, implementation, and oversight of Equity and Community Health initiatives and pilots to reduce racial and ethnic disparities. Coordinate with internal departments and external stakeholders to ensure compliance with state and federal healthcare regulatory standards.
CalOptima Health
18 Remote Job Openings at CalOptima Health
Oversee daily operations of the Behavioral Health Call Center and Clinical teams to ensure members receive appropriate screenings and care management. Manage licensed clinicians, ensure regulatory compliance with agencies like NCQA and CMS, and coordinate with external community partners.
Regulatory Affairs & Compliance Analyst, Policies & Procedures
CalOptima Health
·
Full Time
·
13 hours ago
CalOptima Health
The analyst supports the development, communication, and implementation of organizational policies to ensure compliance with federal and state requirements. Key duties include performing technical reviews of policies, managing tracking tools, and supporting regulatory audits.
Oversee peer review functions and the end-to-end Potential Quality Issue (PQI) process to ensure regulatory compliance and member safety. Lead a team of clinical and non-clinical staff while collaborating with internal departments and provider partners to drive quality improvements.
Member Liaison Specialist Sr, Behavioral Health Clinical / Care Management - Covered California
CalOptima Health
·
Full Time
·
2 days ago
CalOptima Health
Provides advanced support to behavioral health members by coordinating complex cases, crisis calls, and linkage to care providers. Acts as a consultative liaison between members, health networks, and community agencies to ensure timely access to services.
Member Liaison Specialist Sr - Covered California (BHI-BHT/ABA)
CalOptima Health
·
Full Time
·
2 days ago
CalOptima Health
Provide care management support for members seeking Behavioral Health Treatment and Applied Behavior Analysis services. Act as a consultative liaison between members, providers, and community agencies to coordinate medical and social services.
Business Analyst Sr, Claims - Covered California
CalOptima Health
·
Full Time
·
2 days ago
CalOptima Health
The role involves translating complex business needs into analytical solutions and serving as the subject matter expert for Covered California claims. Key duties include analyzing regulatory changes, coordinating user acceptance testing, and providing training on system configuration.
Clinician Sr, Behavioral Health - Clinical/Care Management - Covered California (Clinician Sr)
CalOptima Health
·
Full Time
·
2 days ago
CalOptima Health
Provide advanced behavioral health care management services, including clinical assessments and the development of member-specific care plans. Coordinate care between providers and stakeholders while supporting the behavioral health call center with screenings and crisis intervention.
Manage medical appeals and state hearing reviews by investigating clinical information and preparing case narratives. Represent the organization at state hearings and ensure all resolutions meet regulatory requirements and timelines.
Grievance Resolution Specialist (Provider Resolution)
CalOptima Health
·
Full Time
·
11 days ago
CalOptima Health
Coordinate the resolution process for grievances and appeals from members and providers regarding eligibility, benefits, and claims. Collaborate with internal departments and external stakeholders to ensure timely case disposition and regulatory compliance.
Provider Data Management Services Coordinator Sr, Covered California
CalOptima Health
·
Full Time
·
12 days ago
CalOptima Health
Responsible for building and maintaining provider records in the CalOptima Health system to ensure data accuracy and completeness. Acts as a liaison between health networks and providers while leading projects and resolving complex data quality issues.
Data Engineer, Platform Modernization (Data Warehouse Programmer/Analyst)
CalOptima Health
·
Full Time
·
13 days ago
CalOptima Health
Responsible for modernizing legacy data estates by retiring Microsoft Access databases and porting SQL Server stored procedures to a cloud-native platform. Collaborates with Data Governance and cross-functional teams to document business rules and implement a medallion data architecture.
Conduct ongoing data quality auditing of provider network data and collaborate with internal departments to remediate errors. Ensure compliance with regulatory guidelines and internal policies while providing analytical support for provider data operations.
The QI Nurse Specialist manages the quality of care grievance review process and conducts investigations into potential quality issues. They are responsible for collecting data, preparing reports for the Medical Director, and ensuring compliance with regulatory standards.
Member Liaison Specialist (Behavioral Health)
CalOptima Health
·
Full Time
·
20 days ago
CalOptima Health
Assist Medi-Cal and OneCare members with behavioral health care management and appointment securing in a call center environment. Act as a liaison between members, providers, and community agencies to coordinate behavioral health services and support integration initiatives.
Oversee daily case management operations, ensuring compliance with NCQA, CMS, and DHCS regulations. Lead and mentor a team of case managers while collaborating with providers and community partners to improve member health.
Covered California Claims and Billing Architect (ITS Architect III)
CalOptima Health
·
Full Time
·
a month ago
CalOptima Health
The architect will lead the design and delivery of scalable cloud-based claims and billing solutions to support digital transformation. They will collaborate with stakeholders to define enterprise technology blueprints and provide technical oversight for implementation.
Covered California Architect (ITS Architect IV)
CalOptima Health
·
Full Time
·
a month ago
CalOptima Health
The architect is responsible for defining and implementing innovative technical solutions for the Covered California program within a health plan environment. This includes leading cross-functional initiatives, managing vendor consultants, and ensuring scalable integration with existing systems.
