PACE Health Plan Manager; Valley PACE - Ceres Whitmore

Responsible for providing oversight and coordinating the daily operations of health plan objectives including contracts, compliance, credentialing, communication, authorizations/claims, and disputes in a manner that meets established turnaround, quality and production goals, and regulatory standards.

Located at Central Valley PACE - Ceres, CA

Schedule is Monday – Friday, working from 8:00am – 5:00pm

Compensation: $82,347.20 – $86,464.56 Annually

• Plans and assigns work; monitors department workload to ensure mandated turnaround times are met; makes timely and effective adjustments.
• Identifies, monitors and analyzes appropriate metrics; develops timely and effective corrective action plans based on findings.
• Develops, implements and maintains department policies and procedures; makes recommendations for revisions; communicates changes to appropriate individuals in a timely and effective manner.
• Facilitates relationships with contracted third part administrators and other first tier, downstream and related entities (FDR’s).
• Monitors communications with the California Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS).
• Coordinates the compliance and fraud, waste and abuse program with direction from the PACE Medicare Compliance Officer and Executive Director.
• Responds to and resolves or facilitates resolution of complex issues including enrollments/disenrollments, authorizations/claims, appeals, provider disputes, and third party liability cases.
• Assists with the development and implementation of department-related upgrades and enhancements of transaction system and other tools.
• Identifies, monitors and analyzes transaction system processing issues; corrects or escalates as required.
• Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required.
• Prepares for and participates in regulatory audits: compiles audit packets, provides information, develops and monitors timely and effective corrective action plans.
• Executes and monitors business plans; assists in the development and monitoring of department budget.
• Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
• Promotes and maintains an environment that supports GVHC’s strategy, vision, mission and values.
• Hires, supervises and retains staff.
• Oversee outreach, enrollment and marketing.
• Assists in developing department objectives and business plans.
• Other duties as required.

• Ability to lift up to 30 pounds. Moving, lifting or pushing greater than 30 pounds, should be done with assistance as appropriate.
• Must be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
• Must have vision with or without lenses that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
• Must have high manual dexterity.
• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.

• Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.
• Subject to unpleasant odors.
• The noise level is usually quiet to moderate, but may at times be noisy and crowded.

• Work is varied and moderately complex, and requires a moderate degree of discretion and independent judgment.
• Valid California Driver’s License, acceptable driving record and vehicle insurance.
• Ability to direct and manage staff in multiple disciplines.
• Must have strong communication and presentation skills, both oral and written.
• Bilingual:
  Spanish/English preferred.
• Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
• Strong interpersonal skills, analytical and team leading skills.
• Identify and solve problems; collect, correlate and analyze data.
• Detail…