PACE Business Analyst

PacificSource•Springfield, OR

1d•$58,074 - $92,919

About The Position

Looking for a meaningful way to make a difference in the lives of older adults? At PacificSource PACE LLC, you will be part of a team that provides compassionate, coordinated care that helps participants live safely, independently, and with dignity. Our approach honors the whole person, and that includes the people who work here. At PACE, you will join colleagues who value respect, connection, and shared purpose. We create space for every team member to contribute their strengths, grow in their role, and feel supported in the important work of caring for our community. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to disability, veteran status, race, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, age, or any other protected status. We are committed to reflecting the diversity of the communities we serve and creating a workplace where differences are celebrated and everyone can thrive. The PACE Business Analyst plays a critical role in supporting data-driven decision-making across clinical and financial operations. This position is responsible for analyzing utilization management data, evaluating HCC (Hierarchical Condition Category) coding models, coordinating the one-third Financial Audit, Part D Bid(s), reviewing IBNR (Incurred but Not Reported) claims estimates, and providing actionable insights to the Chief Medical Officer and Program Director for budgeting and financial performance. The ideal candidate will possess strong analytical skills, healthcare finance knowledge, and a deep understanding of managed care operations.

Requirements

Minimum of 3 of experience in healthcare finance, preferably in a PACE, Medicare Advantage, health system, or managed care setting.
Bachelor’s degree required.
Strong knowledge of CMS regulations, HCC coding, and Part D financial requirements.
Proficiency in data analysis tools (e.g., Excel, SQL, Workday, Power BI, Tableau).
Excellent communication and presentation skills.
Ability to work independently and collaboratively in a fast-paced environment.
Each member of the PACE organization's staff that has direct contact with participants must meet the following conditions: Be legally authorized (for example, currently licensed, registered or certified if applicable) to practice in the State in which he or she performs the function or action. Only act within the scope of his or her authority to practice. Have 1 year of experience working with a frail or elderly population Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently. Be medically cleared for communicable diseases before engaging in direct participant contact.

Nice To Haves

Experience working with geriatric or frail populations is preferred.
Preferred areas of study: accounting, healthcare administration, finance, business, data analytics, or related field.
Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.
Experience with actuarial modeling or financial forecasting.
Familiarity with Electronic Health Record systems and claims data structures.
Understanding quality metrics and value-based care models.

Responsibilities

Analyze trends in service utilization, hospital admissions, and care coordination.
Identify cost drivers and opportunities for care optimization.
Collaborate with IT in the development of dashboards and reports to monitor key utilization metrics from both claims-based and Electronic Health Record (EHR) data.
Evaluate HCC coding trends and the impact to Per Member Per Month payments.
Collaborate with coding and clinical teams to improve risk score capture.
Collaborate with the Finance and Actuarial Teams to model financial impacts of coding changes on capitation payments.
Serve as the primary liaison for the annual Centers for Medicare and Medicaid Services (CMS) one-third Financial Audit.
Coordinate data collection, validation, and submission processes.
Participate in the development of the Part D bid.
Collaborate with compliance regarding CMS audit requirements and timelines.
Develop annual PS PACE Budget.
Review actuarial estimates of IBNR claims.
Validate assumptions and methodologies used in IBNR calculations.
Provide insights to support accurate financial forecasting and reserve setting.
Monitor and validate the accuracy of medical and pharmacy claims adjudication.
Identify and resolve discrepancies or errors in claims processing.
Reconciliation of Residential and Long Term Care services claims as compared to PACE Interdisciplinary Team authorized services.
Collaborate with the pharmacy benefit manager (PBM) and internal teams to ensure compliance with CMS guidelines and cost containment strategies.
Prepare presentations and reports for senior leadership.
Translate complex data into clear, actionable recommendations.
Support strategic planning and budget development processes.
Meet department and company performance and attendance expectations.
Follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.