Operations Oversight Analyst

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

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.

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.

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 Statement(s)

• 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.

• Other duties as assigned/

POSITION QUALIFICATIONS

Competency Statement(s)

• 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: 5 plus years of experience in a claims processing 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. Excellent understanding of claims regulatory requirements including but not limited to AB1455, AB97, COB and clinical editing (NCCI): strongly desired

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

WORK ENVIRONMENT

Office work environment.