PACE Health Plan Manager (Central Valley PACE - Ceres Whitmore)

Available Staff Positions•Modesto, CA

18h•$82,347 - $86,465•Onsite

About The Position

Responsible for providing oversight and coordinating the daily operations of health plan objectives including contracts, compliance, credentialing, communication, authorizations/claims, and disputes in a manner that meets established turnaround, quality and production goals, and regulatory standards. Located at Central Valley PACE - Ceres, CA Schedule is Monday – Friday, working from 8:00am – 5:00pm Compensation: $82,347.20 – $86,464.56 Annually

Requirements

Work is varied and moderately complex, and requires a moderate degree of discretion and independent judgment.
Valid California Driver’s License, acceptable driving record and vehicle insurance.
Ability to direct and manage staff in multiple disciplines.
Must have strong communication and presentation skills, both oral and written.
Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
Strong interpersonal skills, analytical and team leading skills.
Identify and solve problems; collect, correlate and analyze data.
Detail oriented, precise and well organized.
Able to meet short deadline projects with quality work.
Meet a standardized set of orientation and/or individual competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.
Bachelor's Degree in Business, Accounting, Finance, or related field; or four years of equivalent relevant work experience in lieu of degree.
Minimum four (4) years progressively responsible experience with Health Plan processes, compliance, and reporting.
Minimum four (4) years’ supervisory experience required.

Nice To Haves

Bilingual: Spanish/English preferred.
Master’s degree preferred.
Familiarity with CMS/HPMS information technology within CMS and/or HPMS is preferred.

Responsibilities

Plans and assigns work; monitors department workload to ensure mandated turnaround times are met; makes timely and effective adjustments.
Identifies, monitors and analyzes appropriate metrics; develops timely and effective corrective action plans based on findings.
Develops, implements and maintains department policies and procedures; makes recommendations for revisions; communicates changes to appropriate individuals in a timely and effective manner.
Facilitates relationships with contracted third part administrators and other first tier, downstream and related entities (FDR’s).
Monitors communications with the California Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS).
Coordinates the compliance and fraud, waste and abuse program with direction from the PACE Medicare Compliance Officer and Executive Director.
Responds to and resolves or facilitates resolution of complex issues including enrollments/disenrollments, authorizations/claims, appeals, provider disputes, and third party liability cases.
Assists with the development and implementation of department-related upgrades and enhancements of transaction system and other tools.
Identifies, monitors and analyzes transaction system processing issues; corrects or escalates as required.
Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required.
Prepares for and participates in regulatory audits: compiles audit packets, provides information, develops and monitors timely and effective corrective action plans.
Executes and monitors business plans; assists in the development and monitoring of department budget.
Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
Promotes and maintains an environment that supports GVHC’s strategy, vision, mission and values.
Hires, supervises and retains staff.
Oversee outreach, enrollment and marketing.
Assists in developing department objectives and business plans.
Other duties as required.