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

Available Staff Positions•Ceres, CA

8d•Onsite

About The Position

The Central Valley PACE Health Plan Specialist supports the team through data analysis, interpretation, reporting, and modeling health plan operations. This role supports aspects of monthly and ad hoc reporting and assists in the preparation of pro formas based on historical, comparative, and projection data. The specialist will assist to ensure health plan operations, processes, procedures, policies, and compliance efforts are in compliance with regulatory agencies.

Requirements

Valid California Driver’s License, acceptable driving record and vehicle insurance.
Current BLS CPR Card certified by American Heart Association or American Red Cross.
Proven analytical ability, problem solver, collaborate well in a team environment and demonstrate the ability to learn quickly.
Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
High School Diploma or equivalent
Minimum two (2) years claims or referral processing, contracting, compliance, credentialing, billing and coding experience.

Nice To Haves

Bilingual English / Spanish preferred.
Relational database and financial or operational modeling experience preferred.
Associates degree in business administration, healthcare administration or related field; or two (2) years of equivalent relevant work experience in lieu of degree.
Familiarity with Centers for Medicare & Medicaid Services & Health Plan Management System information technology within CMS and/or HPMS is preferred.

Responsibilities

Assists Central Valley PACE Quality and Compliance efforts to ensure the Health Plan’s lines of business are in compliance with contract(s) with the Centers for Medicare & Medicaid Services (CMS), contract(s) with the Department of Health Care Services (DHCS), and any other applicable regulatory agencies.
Prepares Medicare and Medicaid cost reports and supporting information in accordance with cost report instructions and pertinent regulations.
Receives, researches, coordinates, responds timely and tracks all inquiries and submissions to CMS, and DHCS.
Performs analysis to support outcome and impact based decision making.
Assists in the preparation of other documentation and reports related to Medicare and MediCal reporting and reimbursement, such as MediCal DHCS surveys, Medicare CMS surveys, analysis of impact to organizational financial position from proposed or actual regulatory changes, and others.
Involved in the periodic closing process in relation to Medicare and MediCal payments.
Identifies, analyzes and interprets trends or patterns in complex data sets with a high degree of accuracy.
Develops, updates and reviews Standard Operating Procedures (SOPs) related to the disclosure of marketing and healthcare expenditures to comply with federal and state legislative requirements.
Maintains and updates SOP's, work instructions and other foundational department documents to reflect current practices on an on-going basis.
Creates and maintains departmental policies and procedures to reflect changes in regulation to departmental processes.
Develops external and internal policies and procedures.
Ensures health plan marketing materials are maintained in compliance with CMS regulations and requirements.
Create and maintain member and marketing material style guides to reflect regulatory updates to marketing requirements and/or departmental processes.
Assists in preparing the Health Plan for regulatory audits.
Reports potential risks, non-compliance or alleged violations to the Quality and Compliance departments.
Observes each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the licensed nurse.
Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties
Proactively identifies areas of improvement for the Quality and Compliance Departments and participates in development of performance improvement initiatives.
Assists in maintaining regulatory reporting structure in conformance to contracts with CMS and DHCS.
Submits documents to CMS via Health Plan Management System (HPMS) as required per CMS regulations.
Create and maintain health plan network authorizations and scheduling for PACE participants according to CMS and DHCS regulation guidelines.
Facilitate coordination of benefits, manage outside medical appointments, and procure necessary medical equipment, contracting and organization of medical records.
Other projects and duties as assigned.