PACE Health Plan Specialist (Central Valley PACE - Stoddard)
About The Position
The Central Valley PACE Health Plan Specialist supports health plan operations through data analysis, interpretation, reporting, and modeling. The role supports monthly and ad hoc reporting and helps prepare pro formas using historical, comparative, and projection data. It also helps ensure that health plan operations, processes, procedures, policies, and compliance efforts meet regulatory requirements. The position assists with Medicare and Medicaid cost reporting, regulatory submissions and inquiries, reimbursement reporting, financial analysis, documentation, and preparation for regulatory audits. It develops and maintains policies, procedures, work instructions, and marketing-material guidance in response to regulatory requirements. The specialist also observes participants for changes in functioning and reports changes to a licensed nurse, while interacting professionally and respectfully with older adults, including people with cognitive decline or physical frailties. The role is located at the Stoddard Road site in Modesto, California, and is scheduled Monday through Friday, 8:00 a.m. to 5:00 p.m. Compensation is $25.87–$27.16 per hour.
Requirements
- Valid California Driver’s License, acceptable driving record, and vehicle insurance.
- Proven analytical ability, problem-solving skills, ability to collaborate in a team environment, and ability to learn quickly.
- Proficiency in Microsoft Office applications; advanced Microsoft Excel experience is required.
- Current BLS CPR certification from the American Heart Association or American Red Cross.
- High school diploma or equivalent.
- Associate degree in business administration, healthcare administration, or a related field, or two years of equivalent relevant work experience in lieu of the degree.
- At least two years of experience in claims or referral processing, contracting, compliance, credentialing, billing, or coding.
Nice To Haves
- Bilingual English/Spanish.
- Relational database experience.
- Financial or operational modeling experience.
- Familiarity with CMS and/or HPMS information technology.
Responsibilities
- Assist Central Valley PACE Quality and Compliance efforts to ensure health plan lines of business comply with CMS and DHCS contracts and other applicable regulatory requirements.
- Prepare Medicare and Medicaid cost reports and supporting information in accordance with reporting instructions and regulations.
- Receive, research, coordinate, respond to, and track inquiries and submissions to CMS and DHCS.
- Perform analysis to support outcome- and impact-based decision-making.
- Assist with Medicare and Medi-Cal reporting and reimbursement documentation, including surveys and analyses of the financial impact of proposed or actual regulatory changes.
- Participate in periodic closing processes related to Medicare and Medi-Cal payments.
- Identify, analyze, and interpret trends or patterns in complex data sets accurately.
- Develop, update, and review standard operating procedures concerning disclosure of marketing and healthcare expenditures.
- Maintain and update SOPs, work instructions, and other foundational department documents to reflect current practices.
- Create and maintain internal and external departmental policies and procedures reflecting regulatory and process changes.
- Ensure health plan marketing materials comply with CMS regulations and requirements.
- Create and maintain member and marketing material style guides reflecting regulatory updates and departmental processes.
- Assist in preparing the Health Plan for regulatory audits and report potential risks, non-compliance, or alleged violations to Quality and Compliance departments.
- Observe participants for changes in physical, mental, emotional, or social functioning and report changes to a licensed nurse.
- Interact professionally and respectfully with geriatric individuals, including those with cognitive decline or physical frailties.
- Identify opportunities for improvement and participate in developing performance improvement initiatives for Quality and Compliance departments.
- Help maintain a regulatory reporting structure in conformance with CMS and DHCS contracts, including submitting documents through CMS's Health Plan Management System (HPMS) as required.
- Perform other projects and duties as assigned.
Benefits
- Medical coverage, including $0 deductible and individual and family out-of-pocket maximums.
- PPO coverage options.
- Dental coverage.
- Vision coverage.
- 403(b) plan with employer match.
- Flexible spending account plans.
- Gym discounts.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
