Gold Coast Health Plan

Operations

• 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.

Operations Oversight Analyst

Manager

• Develop and manage a comprehensive Care Management program to coordinate medical and social services
• Promote positive health outcomes and cost-effective management of health care resources
• Act as advocate and liaison between providers, members and GCHP to integrate complex services
• Develop protocols to review, screen and prioritize cases for case management services
• Develop tools to ensure delivery of comprehensive care management services and auditing methodologies
• Mentor and supervise a large staff of Registered Nurses, Social Workers, and support staff; ensure protocols and workflows are followed
• Identify problems through dialog with staff and implement solutions to improve deficiencies
• Ensure staff inclusion in department decisions and continually reassess staffing needs
• Participate in development of annual Care Management Work Plan and annual evaluation
• Collaborate with community agencies and other Gold Coast departments to resolve resource deficiencies
• Travel to multiple sites and locations; attend evening meetings and work irregular hours as needed

Manager, Clinical Care Management

Data Engineer

• Reports directly to Executive Director, IT as a trusted customer advocate and helps understand and adopt best practices in Data Operations Management through collaboration and communication across all levels of Gold Coast Health Plan
• Participate in building a culture of Automation: embrace errors, embrace change, create value for customers, create and adopt best practices
• Continuously assess and evaluate outcomes of projects to ensure successful delivery
• Participate in regular review of existing technology solutions and recommend approaches to improve service delivery for the GCHP infrastructure team
• Develop, maintain, and build roadmap and backlog of activities in DevOps and provide Kanban updates and burndown reports
• Cross train team on technical platform specifications with use cases for software and hardware requirements
• Continually upskill for upgrade information on industry products and solutions through trade journals, professional associations, networking, training and seminars
• Participate in governance and management of all infrastructure projects within GCHP
• Communicate cross-functionally and provide technical direction for data products and implementing solutions
• Provide technical mentorship to junior engineers and contribute to development of policies, strategies and best practices, participating in management meetings and following escalation and change control procedures

Senior Data Operations Engineer

• Develop a comprehensive program to coordinate medical and social services for members to meet health care and social determinants of health needs
• Promote positive health outcomes and act as an advocate and liaison between providers, members and GCHP
• Identify members who can benefit from care coordination services and reduce consumption of health care services
• Mentor staff and develop a cohesive team environment
• Work with community agencies to collaborate on mutually benefitting initiatives
• Participate in development of programs to identify members at risk for care management services
• Develop protocols to review, screen and prioritize cases for possible case management services
• Develop tools to ensure the delivery of comprehensive care management services
• Mentor staff to ensure protocols and workflows are being followed and that Care Management services are efficient and effective
• Identify problems through dialog with staff and institute solutions that improve or correct deficiencies
• Ensure staff are included in department decisions to ensure support for new processes
• Develop auditing methodologies to provide feedback to staff on areas where improvements may be needed
• Identify deficiencies in appropriate health care resources and work with other Gold Coast Departments to resolve issues
• Participate in development of an annual Care Management Work Plan and annual evaluation outlining goals, objectives and accomplishments
• Continually reassess department staffing needs to ensure adequate resources are available

Clinical Care Manager

• 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.

Data Analyst

• Act as the Analytical and Technical expert and provide analytic leadership to support Gold Coast Health Plan (GCHP) Analytics team
• Work closely with business and technology leaders to develop innovative analytic solutions, create actionable insights and drive better decisions and performance
• Maintain and enhance the overall quality of healthcare provider data from each disparate source system
• Perform data quality checks for each data source system
• Prepare scorecards/dashboards on data quality and data governance metrics
• Resolve profile and affiliation data issues on a case-by-case basis
• Effectively convey the business rules and definitions and promote them within the business areas
• Contribute to the HL7/FHIR data model and provide business rules and definitions
• Provide business requirements and work with IT system analysts during system development
• Keep Product/Capability Owners and IT informed of business changes that impact data
• Engage with application subject matter experts to understand processes, rules, requirements and deficiencies of healthcare provider data
• Develop business requirements and participate on IT projects focused on developing master data management capabilities
• Manage the client intake requests and build into ad-hoc request
• Establish process to report model output and achieve historical data
• Control quality of work flow and document the process
• Enhance the accuracy of model outputs to optimize operational performance and achieve financial targets

Principal Data Analyst

Analyst

• Enhance and strengthen Gold Coast Health Plan’s policy infrastructure/platform involving state and federal Medicaid programs by tracking and analyzing legislation and regulation
• Conduct policy research and analysis and keep executive staff abreast of regulations and statutes concerning Medicaid/Medi-Cal Programs
• Work on projects and assignments in the Government and Community Relations Department relating to strategic policy objectives and initiatives concerning Medicaid/Medi-Cal
• Provide guidance to internal customers on policy implications and recommendations for policy decisions
• Draft memoranda and reports on policies and procedures concerning state and federal Medicaid programs
• Author GCHP policy briefs and publications, develop figures, tables, charts, data visualizations, fact sheets, and supporting documents
• Monitor activities by the Executive Branch and Congress that may impact the health plan; alert and advise the Executive Director of Strategy and External Affairs on emerging opportunities or concerns
• Perform other ad hoc assignments and projects in support of GCHP departments

Senior Policy Analyst

Auditor

Leads, coordinates, participates in delegation oversight and internal audits of vendors, service providers, delegated providers and internal departments
Serves as liaison between subcontracted providers and leadership
Assists with clinical oversight audit process, develops reports, analyzes and trends audit findings
Supports compliance department and regulatory audit preparation
Coordinates scheduling, audit findings development, writing audit reports and corrective action plans
Maintains audit recordkeeping and deadlines
Oversees revision of delegation oversight audit tools per ICE, NCQA, State/Federal guidance
Provides training, education, consultation to delegates
Collaborates on Joint Operations Meeting agenda development
Presents at Compliance and Quality committees and creates memos, charts, graphs
Assists in development and implementation of quality improvement, remediation, corrective action plans
Supports audit projects with clinical components
Other duties as assigned

Delegation Oversight Auditor I

• Track and analyze federal, state, county, and city policies and trends affecting Medicaid/Medi-Cal.
• Conduct policy research and analysis and determine potential Plan impact from Department of Health Care Services regulations and statutes.
• Provide guidance to internal customers on policy implications and recommendations for policy decisions.
• Draft memoranda and reports on policies and procedures concerning state and federal Medicaid programs.
• Author policy briefs and publications, including figures, tables, charts, data visualizations, and fact sheets.
• Keep executive staff abreast of new policy developments affecting Medicaid/Medi-Cal and low-income coverage.
• Monitor Executive Branch and Congressional activities that may impact the health plan; alert and advise Executive Director of Strategy and External Affairs.
• Work on projects and ad hoc assignments supporting Government and Community Relations and other GCHP departments.
• Perform other duties as assigned.

• Develop a comprehensive program to coordinate medical and social services for members to meet healthcare and social determinants of health needs.
• Promote positive health outcomes and reduce consumption of healthcare services through care coordination.
• Act as an advocate and liaison between providers, members and GCHP to integrate complex services.
• Identify members who can benefit from care coordination and develop mechanisms for identification.
• Develop protocols to review, screen and prioritize cases for case management services.
• Develop tools to ensure delivery of comprehensive care management services.
• Mentor staff (Registered Nurses, Social Workers, Support staff) and ensure adherence to protocols and workflows.
• Identify problems with staff dialogue and institute solutions to improve deficiencies.
• Include staff in department decisions to support new processes.
• Develop auditing methodologies to provide feedback and areas for improvement.
• Identify deficiencies in healthcare resources and coordinate with other departments to resolve issues.
• Participate in development of annual Care Management Work Plan and evaluations.
• Continually reassess department staffing needs to ensure adequate resources.

• Lead, coordinate and perform pre-delegation and routine audits for delegates related to clinical program oversight
• Coordinate scheduling of audits, develop audit findings, aggregate and analyze results, and write audit reports including corrective action plans (CAPs)
• Assist in development and implementation of quality improvement, remediation plans and CAPs based on risk analysis and audit findings
• Maintain accurate recordkeeping of all audits and ensure deadlines are met
• Oversee and assist in revision of delegation oversight audit tools per ICE, NCQA, Plan policies, State and Federal guidance
• Provide training, education, and consultation to delegates as necessary
• Collaborate with Delegation Oversight staff and Health Services to develop Joint Operations Meeting (JOM) agendas
• Present at Compliance Committee, Quality Improvement Committee, and create memos, charts and graphs for presentations
• Monitor delegated activities to ensure compliance with NCQA, CMS and State Medicaid requirements and delegation agreements
• Support Audit projects with clinical components and assist with regulatory audit preparation and coordination
• Serve as liaison between subcontracted providers and the Plan; support the compliance department and convey regulatory requirements

Software Engineer

• Develops and supports reporting, ETL, data driven business decisions, and systems integration from technical specifications.
• Works with Business Systems Analysts, Business Stakeholders, vendors, and solutions partners to develop solutions for operational and ad-hoc reporting, ETL, data driven business decisions support, and systems integration.
• Design and develop SQL Server stored procedures, functions, views and triggers; implement processes and logic to extract, transform, and distribute data across data stores from a wide variety of sources.
• Provides analysis and development support for initiatives, including business function support for system migrations and consolidations, business area process improvement projects, and product installations.
• Develops and/or reviews departmental business system requirements and business systems design documents, customer acceptance test plans, and post-implementation plans.
• Works directly with external customers or in collaboration with the Senior Developers in implementing new reporting capabilities, systems enhancements and technology.
• Work with Analysts and Business Users to translate functional specifications into technical designs for implementation and deployment.
• Provides analysis of efficiencies related to system enhancements/automation.
• Refine and automate regular processes, track issues, and document changes.
• Review of use cases and test cases.
• Developing use cases and test cases.
• Executes system testing.
• Facilitates and support user acceptance testing.
• Perform and execute data extraction, transformation and loading using ETL tools.
• Convert physical data integration models and other design specifications to source codes.
• Managing data analysis and integration of disparate systems
• Building intensive data acquisition and integration solutions in line with business requirements
• Perform and execute data extraction, transformation and loading using ETL tools.

Operations Oversight Analyst

Manager, Clinical Care Management

Senior Data Operations Engineer

Clinical Care Manager

Operations Oversight Analyst

Principal Data Analyst

Senior Policy Analyst

Delegation Oversight Auditor I

Senior Policy Analyst

Manager, Clinical Care Management

Delegation Oversight Auditor I

Developer II