Senior Managed Care Analyst (H)

Kaweah Health•Visalia, CA

2d•$37 - $56

About The Position

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community. Provides technical and consulting support regarding all Managed Care contracts within the Kaweah Health. Ensures effective audit/review of all data sources in preparation of reporting of all managed care contracts, including the maintenance of adequate internal systems and controls. Supports management decisions by providing financial analyses and forecasts of operations through timely reporting and data analysis. Responsible for managed care contract review and analysis, capitation contract reporting and contract fulfillment analysis within the Managed care department. Assists management in contract implementation with various departments. Supports operations and contract interpretation to departments within the Kaweah Health. Completes special projects as assigned and analytically reviews departmental output and the associated applications.

Requirements

Education Required:MBA or Bachelor’s degree
Experience Required:Minimum of two years of healthcare/healthcare auditing, patient accounting, managed care contracting or medical group practice field.
Minimum of ten years’ experience in healthcare or related field (only required if candidate does not have an MBA).
Possesses excellent analytical, mathematical, deductive reasoning and problem solving skills and the ability to work collaboratively and communicate effectively with all levels of management and staff.
Proficiently organizes, analyzes and presents financial information.
Operates in a productive, self-motivated and forward-thinking manner.
Possesses proficiency with computer technology and in developing and maintaining effective microcomputer spreadsheet applications.
Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area.
Performs other duties as assigned.

Nice To Haves

Preferred:Bachelor’s degree with an emphasis in business, finance, accounting or health care administration.
Preferred:Managed Care experience

Responsibilities

Supports management with decisions by providing financial analysis and forecasts of claims paid data, provides managed care expertise and support to produce meaningful, timely, accurate and understandable information which enhances the decision-making process.
Analyzes monthly claims paid data results, researches significant variances within a timely manner and reports results to management.
Develops and maintains tools such as trend reports, utilization dashboards and financial analysis.
Analytically and critically reviews and evaluates both financial and clinical data from multiple sources and compiles usable, accurate and concise reports for leadership to make informed decisions regarding capitated membership.
Assists in the preparation and submission of all third-party reimbursement and information reports in accordance with established guidelines.
Completes and submits all third-party reimbursement and information reports accurately and within established timeframes.
Develops and maintains expertise sufficient to complete the reports in a reviewable manner and to effectively operate supporting computer software programs.
Processes information for and is proficient in developing and maintaining microcomputer applications. Including but not limited to Microsoft Access database and query building to ensure timely and accurate ad hoc data analysis.
Provides accurate managed care contract interpretations and acts as a liaison between the Kaweah Health and health plans.
Supports the Managed Care Manager/Director in contract analysis, reporting and provider relations.
Effectively utilizes the computer to eliminate manual record keeping and promote greater efficiency.
Recognizes the importance of all reports and information generated for both internal and external processes and the reliance placed thereon for decision-making purposes. All reports, dashboards and information generated are accurate, complete and timely and are subjected to self-review and analysis prior to distribution or submission.
Administers the financial systems. In conjunction with management, designs, implements and maintains the structure and parameters related to these systems. By completing monthly analysis, ensures accurate and timely data is entered into these systems.
Prepares/runs monthly reports from these systems and distributes to management or other responsible managers/directors/executives.
Completes special projects as assigned and analytically reviews departmental output and the associated applications.
Completes special projects accurately, thoroughly, timely and in a manner which allows for effective review. Possesses necessary skills to develop and challenge rational assumptions and forecast methodologies.
IF ASSIGNED TO KAWEAH RESPONSIBILITIES:Reconciles, analyzes and prepares all monthly capitation reports for management to review regarding contract fulfillment. Provides interpretation and expertise on all managed care contracts and capitation arrangements, assisting with education on all terms of the contracts. Processes all capitation expenses. Reconciles and reviews all claims paid data from various sources to verify accurate payment for capitation arrangements. Assists leadership with network building for capitation agreements. Assists finance in reporting for reconciliation of the financials. Ensures maximum reimbursement and accuracy of all billed claims for capitated services and reconciles both systems to capture all data elements. Assists Manager with managed care contract analysis by utilizing database, developing queries and building usable and accurate reports for health plan contracts. Assists patient accounting with payor issues by acting as a liaison between the Kaweah Health and all health plans. Prepares ad hoc reporting regards to capitation contracts for all leadership of Kaweah Health, Key Medical Group and Foundation for Tulare/Kings County, SHP and SIH. Assists leadership with implementing and interpreting managed care contracts to Kaweah Health staff, providing guidance on reimbursement and forecasting revenue to Kaweah Health leadership.
IF ASSIGNED TO SEQUIOA INTEGRATED HEALTH RESPONSIBILITIES:Produces reports for the various reporting entities for the Humana shared risk team for capitation services on an as needed basis. Produces and analyzes utilization data from capitation members and provide data to assist with clinical decision. Analyzes claims paid data from all systems to compile and build dashboards and reports used in making decisions. Produces clinical target lists using all data sources that can assist with patient care. Analyzes clinical data from all systems, compiles and builds dashboards and reports utilized by leadership. Utilizes databases and develops queries to import data from different sources to provide leadership with usable information. Reviews all data and reporting to assure accuracy. Produce reporting for physician specific patient admits. Assists Manager with managed care contract analysis by utilizing database, developing queries and building usable and accurate reports for health plan contracts. Assists patient accounting with payor issues by acting as a liaison between the Kaweah Health and all health plans. Prepares ad hoc reporting regards to capitation contracts for all leadership of Kaweah Health, Key Medical Group and Foundation for Tulare/Kings County, SHP and SIH.