PACE Health Plan Specialist (Central Valley PACE - Stoddard)

Available Staff Positions • Modesto, CA

20h • Onsite

About The Position

The Central Valley PACE Health Plan Specialist supports health plan operations through data analysis, interpretation, reporting, and modeling. The role assists with monthly and ad hoc reporting and preparation of pro formas using historical, comparative, and projected data. It also supports compliance with applicable regulations, contracts, policies, and procedures. The position is located on Stoddard Road 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.

The specialist assists with Medicare and Medicaid reporting and reimbursement, regulatory inquiries and submissions, audit preparation, and maintenance of policies, procedures, and marketing materials. The role also observes PACE participants for changes in functioning and reports those changes to a licensed nurse. The position involves interaction with geriatric individuals, including people with cognitive decline or physical frailties.

Requirements

• Valid California Driver’s License, acceptable driving record, and vehicle insurance.
• Demonstrated analytical ability, problem-solving skills, ability to collaborate in a team environment, and ability to learn quickly.
• Proficiency in Microsoft Office applications and advanced Microsoft Excel experience.
• 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.
• Ability to interact professionally and respectfully with geriatric individuals, including those with cognitive decline or physical frailties.

Nice To Haves

• Bilingual English/Spanish.
• Relational database experience.
• Financial or operational modeling experience.
• Familiarity with CMS and/or HPMS information technology.

Responsibilities

• Support 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 applicable instructions and regulations.
• Research, coordinate, respond to, and track inquiries and submissions to CMS and DHCS in a timely manner.
• Perform analysis to support outcome- and impact-based decision-making.
• Assist with documentation and reports related to Medicare and Medi-Cal reporting and reimbursement, including surveys and analyses of regulatory changes and their financial impact.
• Participate in periodic closing processes related to Medicare and Medi-Cal payments.
• Identify, analyze, and interpret trends and patterns in complex data sets accurately.
• Develop, update, and review SOPs related to disclosure of marketing and healthcare expenditures under federal and state requirements.
• Maintain SOPs, work instructions, policies, and other department documents to reflect current practices and regulatory or process changes.
• Ensure health plan marketing materials comply with CMS requirements and maintain member and marketing material style guides.
• Assist in preparing the Health Plan for regulatory audits.
• 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.
• Identify improvement opportunities and participate in performance improvement initiatives for Quality and Compliance.
• Assist in maintaining regulatory reporting structures that conform to CMS and DHCS contracts.
• Submit documents to CMS through the Health Plan Management System (HPMS) as required.
• Complete other projects and duties as assigned.

Benefits

• Medical coverage with a $0 deductible and out-of-pocket maximums of $2,000 individual and $4,000 family.
• PPO coverage.
• Dental coverage.
• Vision coverage.
• 403(b) plan with employer match.
• Flexible spending account plans.
• Gym discounts.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree