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

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

Located at Central Valley PACE - Ceres, CA

Schedule is Monday – Friday, working from 8:00am – 5:00pm

Compensation:

$25.87 - $27.16 an hour

Duties and 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, procure necessary medical equipment, contracting and organization of medical records.


• Other projects and duties as assigned.

Physical Demands

• Ability to lift up to 30 pounds. Moving, lifting or transferring patients may involve lifting or pushing greater than 30 pounds, should be done with assistance as appropriate. 


• Must be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.


• Must have vision with or without lenses that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.


• Must have high manual dexterity.


• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.

Work Environment

• Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.


• Subject to unpleasant odors.


• The noise level is usually quiet to moderate, but may at times be noisy and crowded.

Minimum Qualifications

• Valid California Driver’s License, acceptable driving record and vehicle insurance.


• Bilingual English / Spanish preferred.


• 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.


• Relational database and financial or operational modeling experience preferred.

Education/Experience

• Associates degree in business administration, healthcare administration or related field; or two (2) years of equivalent relevant work experience in lieu of degree.


• Current BLS CPR Card certified by the American Heart Association


• Minimum two (2) years claims or referral processing, contracting, compliance, credentialing, billing and coding experience.