Central California Alliance for Health (Remote)

Provide clinical leadership and oversight for medical management functions including Utilization Management and Provider Disputes. | Doctor of Medicine or Osteopathy with active California license, Board certification, and at least three years of experience in medical programs administration. | ABOUT THIS TEMP POSITION This is a part-time temporary position, and the length of the assignment is estimated to go from December to March with the possibility of extension. The length of the assignment is always dependent on business need and dates may change. While the assignment would be at the Alliance, if selected, you would be an employee of a temporary employment agency that we would connect you with. The time commitment for this position is 8-16 hours per week (depending on what works best for you) during our standard business hours of Monday-Friday 8am-5pm. There could be some schedule flexibility for the right candidate. This position will support our five service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa, California; however, you will be working fully remotely in California or the greater US with a valid California Board Certified Medical License. WHAT YOU'LL BE RESPONSIBLE FOR Reporting to the Chief Medical Officer, this position will provide clinical leadership and oversight for key medical management functions, including Utilization Management (UM) and Potential Quality Issue (PQI), and Provider Disputes. WHAT YOU'LL NEED TO BE SUCCESSFUL To read the full position description, and list of requirements click here. Knowledge of: Data collection and management practices, as related to utilization and quality of medical care InterQual and Milliman Care Guidelines Managed care, Medi-Cal, Medicaid, and Medicare programs Healthcare regulatory processes Or proficiency with Jiva Ability to: Independently navigate complex systems to effectively and efficiently implement new programs in a timely manner Communicate clearly and consistently and work collaboratively with stakeholders and partners, such as patients, community-based organizations, and healthcare providers Evaluate, qualitatively and quantitatively, a broad variety of programs and processes and use these evaluations to ensure ongoing quality improvement Education and Experience: Doctor of Medicine or Doctor of Osteopathy from an accredited medical school and a current active and unrestricted license to practice medicine issued by the State of California, Board certification in a specialty recognized by the American Board of Medical Specialties, and a minimum of three years of experience working in medical programs administration, including experience with the peer review process; or an equivalent combination of education and experience may be qualifying. OTHER INFORMATION We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams. While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected. In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process. This is a temporary position and does not provide the benefits that are listed below (it is standard language from our regular job posts and cannot be altered or removed). The full compensation range for this position is listed by location below. The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location). Zone 1 (Monterey, San Benito and Santa Cruz) $175—$185 USD Zone 2 (Mariposa and Merced) $165—$175 USD Zone 3 (National) $125—$135 USD OUR BENEFITS Medical, Dental and Vision Plans Ample Paid Time Off 12 Paid Holidays per year 401(a) Retirement Plan 457 Deferred Compensation Plan Robust Health and Wellness Program Onsite EV Charging Stations And many more ABOUT US We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer Join us at Central California Alliance for Health (the Alliance) is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We currently serve more than 418,000 members. To learn more about us, take a look at our Fact Sheet. At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.

Conduct ongoing compliance reviews, respond to regulatory inquiries, assist with audits, and coordinate subcontractor compliance oversight. | Bachelor's degree with 3+ years compliance experience or equivalent, knowledge of healthcare regulations, audit techniques, and ability to analyze legal and contractual language. | This is a Defined Term position, which is designated by the Alliance and is a position of limited duration. Defined Term employees are usually hired to work in a specific department on specific long-term project work until the work is completed or to a specific end date not to exceed December 31, 2026. This is a Defined Term and fully benefited position. We have an opportunity to join the Alliance as a Compliance Specialist in the Compliance Department. WHAT YOU'LL BE RESPONSIBLE FOR Reporting to the Compliance Manager, this position: • Conducts regular on-going review and analysis of relevant contractual provisions and state and federal statutes and regulations • Researches questions from staff regarding regulatory compliance and responds to external requests for information, including related to Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare & Medicaid Services (CMS) requirements • Assists with the implementation of internal and external audit processes to ensure compliance with federal and state statutes and regulations and provides related program guidance for all lines of business • Coordinates Alliance delegate oversight activities to ensure subcontractors' compliance with state, federal, and Alliance requirements • Performs other duties as assigned ABOUT THE TEAM The Compliance Division interprets requirements, mitigates risk, and holds stakeholders accountable, protecting the organization's integrity and member access to quality healthcare. We are the team that helps employees understand and follow the complex rules and requirements to meet our important compliance obligations. In short, we define and support the Alliance's Culture of Compliance internally and with our external healthcare partners. We perform internal audits and monitoring to help us maintain a compliance program that is always up-to-date with ever-evolving compliance rules and obligations. We also handle and investigate internal concerns related to HIPAA, fraud, waste, and abuse, and conduct prevention and detection activities. THE IDEAL CANDIDATE • Has experience working in a managed care or healthcare environment • Has knowledge of the Medi-Cal and Medicare Advantage programs and related regulations • Is experienced in audits and monitoring, risk assessment, and/or delegate oversight • Has an acute attention to detail and data accuracy • Has experience working remotely and knows how to self-motivate while staying closely connected to their team • Has excellent multitasking skills and thrives in a fast-paced environment • Is efficient with their time and can meet strict deadlines WHAT YOU'LL NEED TO BE SUCCESSFUL To read the full position description and list of requirements, click here. • Knowledge of: • The principles and practices of compliance programs and regulatory processes • Quality improvement practices and related audit techniques • Research, analysis, and reporting methods • State and Federal legislative processes • Ability to: • Quickly understand Alliance roles and responsibilities related to oversight agencies • Identify and research relevant legal materials, and analyze and interpret legal and contractual language • Learn and apply state and federal regulations related to compliance activities • Demonstrate strong analytical and research skills, identify and troubleshoot issues, identify alternative solutions, and make recommendations for action • Education and Experience: • Bachelor's degree in Business or Public Administration, Public Policy, Health Care Planning, or a related field and a minimum of three years of compliance experience (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying. OTHER INFORMATION • We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams. • While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected. • In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process. The full compensation range for this position is listed by location below. The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location). Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area Zone 1 (Monterey, San Benito and Santa Cruz) $69,937—$111,904 USD Zone 2 (Mariposa and Merced) $63,645—$101,837 USD OUR BENEFITS • Medical, Dental and Vision Plans • Ample Paid Time Off • 12 Paid Holidays per year • 401(a) Retirement Plan • 457 Deferred Compensation Plan • Robust Health and Wellness Program • Onsite EV Charging Stations • And many more ABOUT US We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer Join us at Central California Alliance for Health (the Alliance) is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We currently serve more than 418,000 members. To learn more about us, take a look at our Fact Sheet. At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.