Director, Premium Billing and Member Enrollment (Director II)

Director, Premium Billing And Member Enrollment (Director Ii)

CalOptima Health is seeking a highly motivated Director, Premium Billing and Member Enrollment (Director II) to join our team. CalOptima Health is looking for a strategic thinker with a proven track record of leading a high-performing team to establish and manage the Enrollment and Billing function related to Health Insurance Exchange / Marketplace / Covered California product operations. The Director will serve in a leadership role to define and scale up their own team, roadmap, implement, and manage operationalization of this capability at CalOptima Health, and drive closing the people, process, and technological gaps between current state and future state operations to support enrollment and billing capabilities for the Covered California line of business. This role will be critical in standing up and continuing to successfully execute seamless enrollment, accurate billing, and regulatory compliance for the product line expansion.

Position Information :

Department : Customer Service

Salary Grade : 321 - $181,257 - $290,011 ($87.14 - $139.4282)

Work Arrangement : Full Office

Duties & Responsibilities :

45% - Leadership Functions

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.

Directs, hires and trains department managers and staff.

Reviews and develops the performance of department staff and sets monthly or quarterly goals.

Serves as the key point of contact and advisor for executive leadership when making strategic decisions impacting the operations of the Enrollment and Billing function at CalOptima Health.

Develops and executes the 12-18-month roadmap to operationalize Enrollment and Billing capabilities for Covered California line of business - integrating with existing Medi-Cal workflows (where applicable), defining new operational processes, and configuring existing and / or new systems to support Covered California line of business.

Builds out and leads Enrollment and Billing function at CalOptima Health (i.e., recruiting, coaching, and retaining team, setting up governance structure, collaborating cross-functionally with other CalOptima Health functions to identify teams' dependencies, etc.).

Oversees the timely and accurate completion of Covered California enrollment capabilities inclusive of ingestion and processing of 834 enrollment files, plan changes, cancellations, and grace-period management per Covered California rules.

50% - Program Oversight

Implements and oversees end-to-end premium billing capability -including invoice generation, member payments, financial reconciliation (including subsidies) and refunds-ensuring regulatory compliance.

Reconciles membership and premium data with Covered California and internally at CalOptima Health to support regulatory requirements and data accuracy internally on a cyclical basis.

Manages the end-to-end enrollment and billing processing and reconciliation for the off-exchange population.

Oversees integration and management of the enrollment and billing capabilities that third party vendors and delegated health network are responsible and accountable for.

Leads vendor and technology selection for vended capabilities and oversees implementation and integration with the organization's processes and technologies.

Leads the development of processes and configuration of core admin system to support implementation and ongoing optimization of the premium billing capability at CalOptima - inclusive of partnering with CalOptima Health's Information Technology teams (and potentially vendor teams), overseeing system and data integrations, etc.

Develops and manages the annual departmental budget.

5% - Other

Completes other projects and duties as assigned.

Minimum Qualifications :

Bachelor's degree in business, health administration, finance, or related field PLUS 7 years in health-plan operations with at least 5 years in health insurance exchange / marketplace and / or commercial Individual and Family Plan (IFP) enrollment and billing 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.

3 years of progressive management / leadership experience required.

Preferred Qualifications :

Knowledge and prior experience at a health plan leading enrollment and billing functions for an exchange or commercial product.

Specific experience with Covered California.

Required Licensure / Certifications :

N / A

Knowledge & Abilities :

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.

Physical Requirements (With or Without Accommodations) :

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

Work Environment :

If located at the 500, 505 Building or a remote work location :

Work is typically indoors and sedentary and is subject to schedule changes and / or variable work hours, with travel as needed.

There are no harmful environmental conditions present for this job.

The noise level in this work environment is usually moderate.

If located at PACE :

Work is typically indoors in a clinical setting serving the frail and elderly.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

If located in the Community :

Work is typically indoors and sedentary and is subject to schedule changes and / or variable work hours, with travel as needed.

Employee will occasionally work outdoors in varied temperatures.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

About CalOptima Health :

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About our Benefits & Wellness Options :

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical / vision / dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a