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
- 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.
- Assure timely and accurate resolution of identified issues jointly with the GCHP contractor or delegate.
- Perform follow-up with the ASO as necessary to meet commitments.
- Assist in prioritization of provider claims research projects recognizing compliance and business priorities.
- 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 to GCHP and delegates root cause of identified issues to ensure corrective actions are taken to prevent future problems.
- Ensure resolution and action plans are following all regulatory and contractual requirements.
- Remain abreast of Provider Dispute Resolution/Provider Grievance policies and coordinate closely with accountable staff and relevant policies.
- Track remediation activities to be performed by delegates to resolve issues.
- Participate in Provider Education efforts as appropriate and represent Operations in meetings with providers.
- Recommend appropriate 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 appropriate process corrections.
- Coordinate and host joint operation meetings and review service level agreements.
- Produce report analysis and other duties as assigned.
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 including MS Office products.
- 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.
- Ability to travel 30-50% as required.
- Gold Coast Health Plan will not sponsor applicants for work visas (work authorization requirement).
