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Operations Oversight Analyst

Gold Coast Health PlanCamarillo, CA, US

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Job Description

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture :

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace :

Integrity
Accountability
Collaboration
Trust
Respect

Disclaimers :

Flexible work schedule is based on job duties, department, organization, or business need.

Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

Under the direction of the Change Control Manager, the Operations Oversight Analyst coordinates with contracted and delegated entities to provide oversight, review, and feedback related to operational processes. Perform task related to the change control process to ensure change documentation is captured and reported efficiently. This role will also partner with internal departments to provide trending results of oversight review and responds to escalated provider inquiries related to claim submissions and processed claims.

Amount of Travel Required : 30-50%

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

Complete quality review of claims to ensure providers are billing and paid accurately.

Complete quality review of incoming calls to ensure accuracy and completeness of activity.

Validate the effective implementation of Corrective Action Plans (CAPs) through future audits to ensure compliance

Assures timely and accurate resolution of identified issues jointly with the GCHP contractor or delegate.

Performs follow-up with the ASO as necessary to meet commitments

Assists in prioritization of provider claims research projects recognizing compliance and business priorities.

Initiates direct communication with providers and delegates when additional information is required and provides timely updates.

Communicates with providers on resolution and closure of issues, as needed.

Supports prioritization and accurate resolution of change requests.

Communicates to GCHP and delegates root cause of identified issues to ensure corrective actions are taken to prevent future problems.

Ensures resolution and action plans are following all regulatory and contractual requirements.

Remains abreast of Provider Dispute Resolution / Provider Grievance policies and coordinates closely with accountable staff and relevant policies.

Tracks remediation activities to be performed by delegates to resolve issues.

Participates in Provider Education efforts as appropriate. Represents Operations in meetings with providers.

Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes, and adjustments.

Identifies and communicates deficient trends and coordinates with outside vendors and internal management to develop appropriate process corrections.

Coordinate and host joint operation meetings.

Review service level agreements.

Report analysis

Review, approve, track, and assist with completion of change requests based on priority

Other duties as assigned

POSITION QUALIFICATIONS

Competency Statements

Analytical Skills - Ability to use thinking and reasoning to solve a problem.

Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.

Technical Aptitude - Ability to comprehend complex technical topics and specialized information.

Financial Aptitude - Ability to understand and explain economic and accounting information, prepare and manage budgets, and make sound long-term investment decisions.

Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education : High School Graduate or General Education Degree (GED) : Required

Experience :

At least 2 years of experience in a claims processing, oversight and / or delegation department at the professional level

Prior experience as a senior analyst / examiner in a lead capacity preferred

Medi-Cal / Medicaid managed care experience strongly desired

Medicare / DSNP experience strongly desired

Computer Skills : Advanced computer skills included in the MS Office products.

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Analyst Oversight • Camarillo, CA, US

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