Regulatory Affairs and Compliance Analyst (Medicare)

CalOptima

CalOptima Health is seeking a highly motivated Regulatory Affairs and Compliance Analyst (Medicare) to join our team. The Regulatory Affairs and Compliance Analyst (Medicare) will coordinate and maintain CalOptima Health's relationships with regulatory agencies, including but not limited to supporting, enhancing and strengthening CalOptima Health's policy infrastructure, platform and strategy at the state and federal level. The incumbent will ensure contract compliance, statutory and regulatory obligations with the California Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS), coordinate and assess the policies and programmatic implications of compliance activities for CalOptima Health. The incumbent will perform various detailed analyses, including the impact of public policy changes from the state of California and the Federal Government on CalOptima Health. The incumbent will interact and function as a liaison with CalOptima Health's internal departments, external regulatory agencies and organizations.

Position Information:

Department: OOC - Medicare Regulatory Affairs & Compliance
Salary Grade: 309 - $68,015 - $108,824 ($32.70 - $52.3192)
Work Arrangement: Full Telework
**This position is eligible for telework in California.**

Duties & Responsibilities:

95% - Program 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.
Monitors regulatory communications from the DHCS and CMS and maintains daily relationships in support of CalOptima Health's Medicare programs.
Researches and keeps current on local, state and federal health care regulations, updates policies and procedures, determines impact and recommends and facilitates the implementation of necessary action on major initiatives for CalOptima Health's Medicare programs (e.g., integration of new benefits and populations), as well as to other affected departments.
Builds and maintains open lines of communication with regulators and management for ongoing trust and confidence in the program.
Works with CalOptima Health departments in response to inquiries, problem-solving, promoting the agency's mission and the development of marketing materials for the Medicare programs, including the annual member materials (e.g., Evidence of Coverage (EOC), Summary of Benefits (SB), provider directories).
Coordinates, tracks and files regular and ad-hoc reports to DHCS and CMS.
Participates and represents CalOptima Health in meetings and calls with regulators and associations. Summarizes key points and impact on CalOptima Health's Medicare programs.
Supports the activities of the Compliance Committee and assists in the implementation of the compliance work plan.
Identifies and completes investigations of all Medicare complaints and works with Regulatory Affairs and Compliance leadership to communicate the complaint's resolution and corrective action plans (CAPs) to the appropriate agency.
Conducts regular and ongoing compliance validation of all relevant standards, guidelines, waivers, contractual provisions or other regulations to which CalOptima Health must comply.
Supports efforts related to regulatory audits, including supporting the manager with interactions and responses to regulatory representatives for all CalOptima Health Medicare programs and following up with the issuance of CAPs to remediate the non-compliance issues identified in the regulatory audits.
Develops compliance tracking tools as needed.
5% - Completes other projects and duties as assigned.

Minimum Qualifications:

Bachelor's degree PLUS 2 years of experience in health care compliance in a provider or managed care setting 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.
Have access to means of transportation for work away from the primary office approximately 5% of the time required.

Preferred Qualifications:

Master's degree in Public Health, Health Care Administration or related field.
Experience working with regulatory agencies in California.
Experience in health care or health plan requirements.

Required Licensure / Certifications:

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 less than 10 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 Guideregarding 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 18, 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.

To apply, please visit: https://jobs.caloptima.org/jobs/regulatory-affairs-and-compliance-analyst-medicare-505-city-parkway-west-california-united-states

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Regulatory Affairs and Compliance Analyst (Medicare)