Senior Zebrafish Scientist

Department(s): Utilization Management
Reports to: Executive Director, Clinical Operations
FLSA status: Non-Exempt
Salary Grade: M - $85,000 - $141,086

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday, December 14, 2023 at 11:59 PM.
Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

About Cal Optima Health

Are you looking for a career that changes lives? As the single largest health plan in Orange County, Cal Optima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow.

If you’re looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at Cal Optima Health!

About the Position

The Program Manager Sr, Non-Emergency Medical Transportation (NEMT) will provide direct management and coordination of all activities involving NEMT for Cal Optima Health members through various vendors. The incumbent will be a resource to staff and work closely with all key internal and external stakeholders relevant to the NEMT program. The incumbent will be responsible for staying up to date on the latest information about Cal Optima Health member NEMT benefits and regulatory changes related to NEMT and will ensure adherence to established policies and procedures to ensure access to transport for all members requiring NEMT.

The incumbent will work in partnership with the Utilization Management team and direct care providers such as referring physicians, skilled nursing facilities, dialysis centers, health network partners and NEMT vendors and brokers to ensure appropriate delivery of NEMT programs and services to all Cal Optima Health members.

Duties & Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Collaborates with the Executive Director to ensure appropriate monitoring of delegate performance and ensures compliance issues are remediated in conjunction with the health network and Cal Optima Health’s Utilization Management and Customer Service teams.
• Researches regulations and informs delegates of Cal Optima Health and the Cal Optima Health Community Network (CCN) team of any changes to regulatory requirements.
• Educates Cal Optima Health staff and health networks on compliance/regulatory initiatives for NEMT.
• Leads program and project development activities for NEMT related initiatives.
• Serves as Cal Optima Health’s primary contact and expert for NEMT.
• Coordinates and facilitates meetings with internal and external stakeholders.
• Presents monitoring and oversight findings at the Utilization Management Committee (UMC) and other committees as requested.
• Identifies and implements process improvement opportunities for requests for medical appropriateness for NEMT services utilizing medical criteria and/or established policies and procedures in partnership with clinical leadership.
• Serves as a liaison to assist Cal Optima Health’s Member Services staff when receiving calls from members regarding missed trips.
• Assists the member and provider office with the coordination of NEMT services to ensure members receive access to medical services.
• Serves as a liaison to assist Cal Optima Health members with continuity of care services and care.
• Reviews ICD-10, CPT-4 and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
• Identifies and reports any complaints to immediate…