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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. Amount of Travel Required: 30-50% 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. 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. 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. Review service level agreements. Report analysis. Review, approve, track, and assist with completion of change requests based on priority. Other duties as assigned. POSITION QUALIFICATIONS
Competency Statements 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. Oriented - Ability to work effectively with people regardless of their ethnicity, religion, or job type. SKILLS & ABILITIES
Education: High School Graduate or General Education Degree (GED): Required Experience: 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 Medi-Cal/Medicaid managed care experience strongly desired Medicare/DSNP experience strongly desired Computer Skills: Advanced computer skills included in the MS Office products.
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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. Amount of Travel Required: 30-50% 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. 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. 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. Review service level agreements. Report analysis. Review, approve, track, and assist with completion of change requests based on priority. Other duties as assigned. POSITION QUALIFICATIONS
Competency Statements 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. Oriented - Ability to work effectively with people regardless of their ethnicity, religion, or job type. SKILLS & ABILITIES
Education: High School Graduate or General Education Degree (GED): Required Experience: 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 Medi-Cal/Medicaid managed care experience strongly desired Medicare/DSNP experience strongly desired Computer Skills: Advanced computer skills included in the MS Office products.
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