Provider Operations Capitation Specialist
PacificSource

Job Info

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Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

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.

Position Overview:

Positions in this function are responsible for various activities related to the provider network database for capitation payments on Commercial and Government lines of business which may include any or all of the following: database maintenance, reporting and extracting data for various reports and analyses, initiating database improvement. Maintain all necessary data elements for Groups and Providers in our Provider database for all states PacificSource services while compliantly meeting HEDIS and NCQA measurements. This position will research, analyze, summarize, categorize and audit all types of encounters based on response files from the Oregon Health Authority (OHA), as appropriate.

Essential Responsibilities:

• Implement Provider Capitation ID's into Facets system for all lines of business in a timely and accurate manner to ensure proper monthly capitation payouts.
• Monitor monthly compliance and quality reports ensuring Provider Data meets all regulatory and internal Capitation quality requirements.
• Investigate, resolve, and communicate provider issues and changes resulting in timely and accurate capitation payments.
• Conduct monthly capitation meetings on new/refresher processes and regulatory guidelines.
• Collaborate with Provider Operations Level III's to analyze processes and workflows makes recommendations for improvement in capitation accuracy.
• Involved in testing new processes within the Facets and other PacificSource systems.
• Assists staff from other PacificSource departments regarding questions or issues with provider capitation data.
• Assist in implementations of new processes, lines of business, and/or large groups. May include attendance of meetings, testing data loads, data validation, and/or correction of erroneous data pertaining to provider capitation.
• Research requests from internal and external customers on capitation payment errors related to provider setup.
• Work with Provider Service and Reimbursement Specialists to ensure member assignments are accurate, timely and consistent with PacificSource policies and procedures.
• Work with Provider Reimbursement, Provider Contracting, Facets Business Support and Health Services to ensure capitation setup is accurate and timely in accordance with guidelines from OHA as well as PacificSource Policies.
• Efficiently and accurately provide backup for the Provider Operations Specialist III position.
• Capably and positively represents the team in cross-functional meetings.
• Develop policies and procedures related to duties.

Supporting Responsibilities:

• Participate in department training and meetings as needed to become cross-trained and proficient in other areas of the department.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience: Minimum of 4 years related experience in health care including 2 years within Provider Operations or a similar role.

Education, Certificates, Licenses: High school diploma or equivalent required. Associates degree or equivalent experience preferred.

Knowledge:

Fast and accurate data entry skills. Self-motivated. Proficient computer skills, typing, and 10-key required. Medical terminology, CPT/ICD-10 coding preferred. Ability to assist with department training. Ability to prioritize and organize work. Ability to exercise judgment based on knowledge of PacificSource policies and procedures. Be proactive in finding more efficient processes and excellent problem-solving skills. Effective written and oral communication, including diplomacy skills for working with the medical professional community, as well as members enrolled in a PacificSource plan. Demonstrated knowledge of all networks and lines of business required. Must be able to communicate effectively with other members of the Provider Network Department and other related internal staff.

Competencies

Our Values

• Adaptability
• Building Customer Loyalty
• Building Strategic Work Relationships
• Building Trust
• Continuous Improvement
• Contributing to Team Success
• Planning and Organizing
• Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time.

Our Values

• 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 encourage creativity, innovation, and the pursuit of excellence.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

Physical Requirements: 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.