Operations Oversight Analyst
Gold Coast Health Plan
Operations Oversight Analyst
Gold Coast Health Plan
full-time
Posted on:
Origin: • 🇺🇸 United States • California
Visit company websiteSalary
💰 $31 - $47 per hour
Job Level
JuniorMid-Level
About the role
- Coordinate with contracted and delegated entities to provide oversight, review, and feedback related to operational processes.
- Perform tasks related to the change control process to ensure change documentation is captured and reported efficiently.
- Partner with internal departments to provide trending results of oversight review and respond to escalated provider inquiries related to claim submissions and processed claims.
- 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 implementation of Corrective Action Plans (CAPs) through future audits to ensure compliance.
- Assure timely and accurate resolution of identified issues with contractors or delegates.
- Perform follow-up with the ASO as necessary to meet commitments.
- Assist in prioritization of provider claims research projects.
- Initiate direct communication with providers and delegates when additional information is required and provide timely updates.
- Communicate with providers on resolution and closure of issues, as needed.
- Support prioritization and accurate resolution of change requests.
- Communicate root cause of identified issues to ensure corrective actions are taken.
- Ensure resolution and action plans follow regulatory and contractual requirements.
- Remain abreast of Provider Dispute Resolution/Provider Grievance policies and coordinate closely with accountable staff.
- Track remediation activities performed by delegates to resolve issues.
- Participate in Provider Education efforts and represent Operations in meetings with providers.
- Recommend prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes, and adjustments.
- Identify and communicate deficient trends and coordinate with outside vendors and internal management to develop process corrections.
- Coordinate and host joint operation meetings.
- Review service level agreements.
- Report analysis.
Requirements
- High School Graduate or General Education Degree (GED): Required
- 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.
- Advanced computer skills included in the MS Office products.
