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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Provides support, critical judgment and decision making to Provider Network leadership and throughout the organization, regarding network access and adequacy through reporting and research for all lines of business. Responsible for producing regular and off-schedule reporting regarding network adequacy, availability and access. Responsible for partnering with internal and external clients to develop and maintain up-to-date and complete requirements for network access, adequacy and capacity reporting. Responsible for oversight of reporting to ensure associated internal and external deadlines are met. Communicates updates and report findings internally and to external entities including Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), Office of Inspector General (OIG) and State Agencies. Responsible for internally communicating Medicare network gaps and documenting exceptions for CMS. Researches and maintains lists of nearest providers to fill access gaps, providing regular updates to Provider Network leadership. Develops and implements additional quality and process improvement and audit and monitoring opportunities and necessities throughout Provider Network. Develops policies and procedures related to duties. This position requires a high level of accuracy, communication, critical thinking, attention to detail and accountability.
- Research, prepare and audit network adequacy and access reports for critical template submissions, HSD tables and state and federal document filings. Identify need for and run additional report refinements to drill down to specific gaps.
- Maintain the monthly and annual processes of access reports to demonstrate network adequacy and availability according to State, Federal and PacificSource requirements, including but not limited to NCQA, OHA and CMS reporting requirements.
- In partnership with internal and external clients, develop requirements for ad hoc geo access and other reports and analytical supports.
- Develop a library of requirements, standards, policies and procedures to support network access, adequacy and capacity monitoring and reporting.
- In partnerships with internal and external clients, manage the product cycle for analytical products, including analysis & research, specification & modeling, design & creation, validation & testing, evaluation & communication.
- Ensure that analytical products meet internal and external requirements, by ensuring reports are correct, complete, and on-time.
- Make decisions and recommendations on investigation of questionable/ambiguous data for reporting and data accuracy. Identify and manage key partners who are able to validate report findings.
- Act as a liaison for PacificSource between Quest Analytics, Provider Network, Medicare, Medicaid and Compliance teams for communication of state and federal requirements and network adequacy findings.
- Work with Quest Analytics to continuously refine reports to most effectively meet requirements.
- Develop audit protocols, best practices, and processes across multiple teams within Provider Network.
- Educate and train staff from multiple departments in network adequacy and reporting requirements across all states and all lines of business.
- Participate as necessary in internal and external audits as required by accrediting agencies as well as State and Federal agencies/regulators.
- Research gaps in adequacy/availability to locate specific nearest available providers. Maintain list of available gap providers and coordinate with Provider Contract staff to update on a regular basis.
- Where required by State or Federal agencies, maintain list of specific providers and provider types for whom PacificSource is required to pay in-network rates for members due to network gaps, and submit to Facets Business System leadership monthly.
- Pull contract activity reports from OnBase as needed to comply with State and Federal requirements. Retrieve and assemble various reports from Enterprise tools and resources for access reports.
- Develop custom maps, when capacity permits, to support Sales and other internal partners.
SUCCESS PROFILEWork Experience:
- Participate in department training and meetings as needed to become cross-trained and proficient in other areas of the department.
- Act as department representative for education and training for other departments and teams across PacificSource.
- Meet department and company performance and attendance expectations.
- Perform other duties as assigned.
3 years of combined experience in a related healthcare and/or analytic position required. Experience with government reporting and data submissions required.Education, Certificates, Licenses:
High School Education with Associate's degree, or equivalent combination of related experience and education required. BA/BS preferred.Knowledge:
Expert spreadsheet modeling and analytical ability essential. Ability to critically review and interpret complex materials and make recommendations. Fast and accurate data entry skills. Extensive knowledge of medical and insurance industry. Expert understanding and knowledge of all policies and procedures within Provider Network. Ability to prioritize work. Organizational skills. Self-motivation. Effective written and oral communication. Responsible to assist with annual regulatory reporting, and monitoring. Responsible for providing prompt, courteous customer service to PacificSource personnel and all outside contacts. Support PacificSource decisions by being consistently helpful, confident and pleasant while working with a wide variety of personalities. Ability to perform well under pressure and to tightly manage complex details as failure to do so in this role could result in regulatory fines to PacificSource.Competencies:
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.Skills:
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, TeamworkOur Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.Disclaimer:
This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
This job has expired.