CalOptima Health is seeking a highly motivated an experienced Program Manager Sr (Quality Analytics (CMS Stars)) to join our team.  Under the general direction of the Director, the Program Manager Sr for Quality Analytics (CMS Stars) will collaborate and coordinate with leadership to design, implement and evaluate quality programs for the Centers for Medicare & Medicaid Services (CMS) Star Ratings and other similar quality programs. The incumbent will be responsible for the coordination, implementation, lead, coordinate, monitor and complete tasks supporting the development of quality programs and initiatives. The incumbent will monitor cross functional projects and other assignments, including those relating to department efficiency to ensure department strategic objectives and initiatives are met. The incumbent will identify issues and recommend solutions to optimize business decisions and operations. The incumbent will be the subject matter expert (SME) who will design, create and implement programs and benefits and serve as the content and technical advisor to operations and business owners. The incumbent will interact with CalOptima Health’s executives and management, legal counsel and state and federal regulatory agencies. The incumbent will also support CalOptima Health staff on related projects. 

Position Information:

• Department: Quality Analytics
• Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
• Work Arrangement: Partial Telework 
  
  **This position is eligible for telework in California.** 

Duties & Responsibilities:

• 80% - Program Support
  • Leads program design, development and implementation of quality programs impacting, but not limited to, Healthcare Effectiveness Data and Information Set (HEDIS), Managed Care Accountability Sets (MCAS) and CMS Star Rating quality measures consistent with the quality program and workplan.
  • Develops and oversees improvement initiatives related to member surveys including Consumer Assessment of Healthcare Providers & Systems (CAHPS) and Health Outcomes Surveys (HOS).
  • Ensures strategic direction of projects/program is in line with department goals and CalOptima Health’s strategic priorities.
  • Makes moderate to significant improvements of processes, systems or products to enhance performance of job area.
  • Plans and implements multiple and complex projects/programs spanning across business areas.
  • Collaborates with other departments to monitor and analyze data related to quality improvement measure sets.
  • Leads improvement projects in performance improvement projects, quality improvement projects, Plan Do Study Act (PDSA) or other formats.
  • Supports National Committee for Quality Assurance (NCQA) accreditation standard initiatives or projects and provides analysis and evaluation of related activities.
  • Leads strategic program development and management, root cause analysis, impact analysis and coordinates collaborative and quality innovation pilots.
  • Completes statement of work and work breakdown structure for request for proposals (RFP), request for information (RFI), projects, programs and business plans.
  • Oversees, organizes and tracks numerous and diverse activities, timelines and issues.
  • Reviews evidence-based literature for best practices to incorporate into strategy.
  • Develops and oversees the process of written tools for programmatic use, including program plans, surveys and evaluation instruments.
  • Collaborates with other department analysts in the development of program measures of success and outcome reports for programs.
  • Maintains current knowledge of applicable regulations or clinical guidelines related to program development.
  • Stays current on the local, state and federal health care environment, identifies issues that may impact CalOptima Health’s quality program and workplan.
  • Develops, collects and reports on quality incentive programs such as pay for performance and quality withhold program results implemented by DHCS or CMS.
  • Develops initial workplan for assigned projects and assignments, and manages the scope, schedule, budget and quality of the project.
  • Develops workflows, key performance indicator (KPI) dashboards, procedures and/or policies and recommends changes to ensure timely, efficient and effective outputs. 
    
    
• 15% - Administrative Support
  • 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.
  • Drafts presentations, board reports and memos to support leadership.
  • Reviews and updates policies and procedures and ensures knowledge related to assigned programs and projects.
  • Works with all CalOptima Health’s departments in response to inquiries, problem-solving and promoting CalOptima Health’s mission and message. 
    
    
• 5% - Other
  • Completes other projects and duties as assigned. 

Minimum Qualifications:

• Bachelor’s degree PLUS 5 years of health care related work experience in program development, including strategic planning for a start-up program, implementing the program and evaluating evidence-based programs 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.
  
• Experience with CMS Star Ratings, including but not limited to HEDIS, CAHPS, HOS, administrative and pharmacy measures required.
  
• Experience and aptitude for working in a highly matrixed, mission-driven organization required.
  
• Experience with value-based contracts and provider incentive programs like pay for performance required.

Preferred Qualifications:

• Master’s degree in public health, health administration or related field.

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 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options.   For more information, please click on the 2025 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

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 June 3, 2025 at 9:00 PM (PST).  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. 

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening).  Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application.  Please check your email, including your SPAM folder, regularly throughout the recruitment process.  You can also visit your candidate portal to receive the most up to date status of your application.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. 

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.