PACE Health Plan Operations Manager (Full-Time)

Job DescriptionJob Description

Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm or 8:30am-5pm.

Position Summary:

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program that provides coordinated medical and social services to eligible older adults who want to continue living in their own home despite chronic care needs. The Health Plan Operations Manager, under direct oversight of the Vice President of Finance and Operations, is responsible for managing the day-to-day financial and health plan operations of PACE at Hudson Headwaters.

Essential Duties and Responsibilities

• Assist with provider network administration, including contract negotiations support, managing catalog of contracts and single case agreements, properly loading all contracts into required systems/vendors, and managing the provider manual
• Assist with management and oversight of TPA, PBM, pharmacy services, and other key vendors
• Assist with all Medicare Part D operations, including managing PBM and pharmacy services vendors
• Manage enrollment, disenrollment, and billing operations for Medicaid, Medicare, and self-pay
• Manage enrollment data and data systems including data transfers, and the development and management of systems to meet PACE programmatic requirements
• Assist in the development and maintenance of effective monitoring programs for claims processing, enrollment reconciliation, Part D, RAPS, and Encounter Data submissions
• Responsible for claims management including oversight of the adjudication process and funds transfers
• Support reporting required by regulatory bodies (CMS, state), including but not limited to the NYS PACEOR and quarterly CMS financial reports
• Collect and prepare data for utilization review including risk scores and service utilization
• Assist VP of Finance & Contracts with internal financial reporting, budgeting, intercompany transactions, and credit card reconciliations
• Assist with regulatory audits including CMS/state program audits and 1/3rd financial audits
• Key point of contact for coordination of benefits
• Uphold the mission and core values of PHH
• Performs other duties as assigned

Qualifications

The requirements listed below are representative of the knowledge, skills, and ability to perform the essential functions:

• Bachelor’s degree in business, accounting, finance, or related field
• 2+ years of experience in managed care operations
• Experience with claims adjudication processes
• Experience with healthcare EMR systems for reporting, coding, and claims processing
• Experience in working with ICD-10 coding and HCPCS is desirable
• Expert proficiency in MS Excel is required
• Must thrive in team environment, possess good organizational and problem-solving skills
• Excellent verbal and written communication skills required
• Possess a strong customer service and thrive in a patient-first culture
• Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective dynamic professional team relationships
• BLS certified or willing to complete necessary certification

The pay range for this position is $70,000 - $75,000/annually and will be determined based on skills and experience.