Health Plan Specialist - PACE Program - Reseda
Location :
Reseda, CA
Job Type :
Direct
Reference Code :
Reseda
Required Years of Experience :
5 years
Required Education :
High School Diploma
Job Industry :
Healthcare - Health Services
Job Description :
Health Plan Specialist - PACE Program
Reseda, CA
Requirements to Apply:
- High School diploma required, Bachelor's degree preferred
- Certifications/License: CA drivers license, Successful completion of health examination and TB screening
- Experience: 5 years experience in the field of health plan claims management with 2 years supervisory experience. Knowledge about senior health care and PACE.
Pay Rate: $37.00 - $40.00 per hour depending on experience
Schedule: Monday to Friday 8:30am - 5pm
Benefits: Medical, Dental, Vision, Life Insurance, Flex Spending, Vacation Time and Paid Sick Time, Holiday Pay for 9 holidays (New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Day, Yom Kippur, Rosh Hashanah and YOUR BIRTHDAY!)
Responsibilities:
- Serve as a point person to assist vendor with the completion of health plan management set up and maintenance.
- Utilize Vendor Management System to generate reports and review data status.
- Ensure all administrative invoices are added to Oracle research and respond to phone call, email and fax inquiries regarding invoice receipt and payment.
- Submit enrollment and disenrollment to health plan management vendor and DHCS.
- Provide claims to health plan management vendor for processing.
- Verify proper CMS capitation rates vs CMS rate book.
- Review Monthly Membership Report (MMR), review weekly report of authorized and unauthorized claims, review monthly IBNR and accounts payable aging reports, and review semi-annual Risk Adjustment Data reports to identify variances.
- Review weekly report of authorized vs unauthorized claims.
- Collaborate with the health plan management vendor to determine permanently placed SNF participant's share of cost and make proper deductions from monthly nursing home bills.
- Review Semi-annual Risk Adjustment Data reports provided by health plan management vendor to identify variances.
- Participate in monthly teleconferences with health plan management vendor and key staff.
- Remain current on CMS data reporting requirements via the Health Plan Management System (HPMS), NPA conferences calls and CMS Communication
- Understands fiscal issues and is appropriately involved in meeting budget targets.
- And other duties as asked.
Required Qualifications :
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