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Quality Inspector - Spokane/Airway Heights

CalOptima

Quality Inspector - Spokane/Airway Heights

Orange, CA
Full Time
Paid
  • Responsibilities

    The Data Analyst, Sr is responsible for supporting a wide variety of projects with varying complexity and reporting requirements and should possess expertise in data analysis, including member, provider, encounters and claims data. This senior analyst develops and designs reports and creates and maintains databases to support the business requirements of the team and our internal and external customers. The incumbent will be responsible for initiating and overseeing the development and maintenance of provider system agreements, fee schedules, and related processes; and will work with various departments in order to ensure that system agreements are in line with provider contracts and amendments. The incumbent will monitor end-to-end provider configuration to identify, report and track potential issues that could affect claims outcomes. This senior analyst works closely with CalOptima’s Provider Data Management, Regulatory Affairs, Contracting, Network Management and Quality teams to provide meaningful data for quality, process improvement, and regulatory initiatives. This incumbent obtains, understands and communicates reporting specifications from government agencies and other entities.

    POSITION RESPONSIBILITIES:

    • Serves as subject matter expert to the Finance Department for shared risk pool settlements.
    • Interprets new provider contracts and contract changes and formally communicates the setup via a system change request form to IS.
    • Obtains, validates and compiles data from multiple sources to create reports for both external and internal use
    • Oversees various internal and external processes to ensure that the DOFR is appropriately operational.
    • Develops, creates, and maintains an electronic system, with reporting capabilities, for tracking System Change Requests.
    • Assists the Contracting Department in the development of contract language related to claims payment in accordance with system requirements.
    • Coordinates and maintains aggregation and integrity of data being submitted to DHCS and CMS.
    • Works directly with contracting and claims to validate fee schedules.
    • Designs reports from the data warehouse, and/or FACETS as needed while maintaining data integrity.
    • Serves as business lead to IS and other departments for overall provider configuration, including fee schedules and agreements.
    • Develops back-end quality control reports to identify provider and/or agreement configuration issues which may lead to claim processing or other errors.
    • Ensures accuracy and timeliness of CalOptima’s provider directories to include regularly scheduled and ad-hoc reporting requests; distributes and posts reports as appropriate.
    • Follow-ups and/or researches requests regarding provider data.
    • Maintains a working knowledge of relevant DHCS and CMS health care initiatives in which CalOptima participates.
    • Prepares ad-hoc analyses, works on special projects and follows-up and/or researches requests regarding provider data.
    • Other projects and duties as assigned.

    Required Skills

    • Develop and maintain thorough knowledge of data sources used for reporting.
    • Develop and maintain knowledge of CalOptima’s lines of business and health networks.
    • Perform in-depth root cause analysis and develop solutions to complicated issues.
    • Effectively translate business requirements into technical specifications.
    • Work independently and as part of a team under minimal supervision.
    • Develop and maintain effective, productive working relationships with all levels of staff.
    • Work on complex projects and perform data quality analysis.
    • Present information in a useable format and clearly explain the content.
    • Prioritize tasks and schedule work deadlines.
    • Communicate clearly and concisely, both verbally and in writing.
    • Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel and Access - advanced) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.

    Required Experience

    EXPERIENCE & EDUCATION:

    • Bachelor’s degree in Health Care Administration, Business Administration or other related field and/or equivalent work experience required.
    • 4 years of data analytic experience required.
    • 4 years of experience working with practice management software required (FACETS preferred).
    • 3 years of managed care experience required, system configuration and/or claims experience preferred.
    • 4 years of provider configuration experience preferred.
    • Medi-Cal, Medicare, and Healthcare Administration experience preferred.
    • Experience working with healthcare IT systems and analyzing managed care risk pool claims and/or data preferred.

    KNOWLEDGE OF:

    • SQL and VBA.
    • GeoAccess software.
    • Advanced MS Access, to create ad-hoc reports and design databases; strong competence with the process of data retrieval from Data Warehouses and databases, creating user-friendly forms and reports.
    • Medical and Revenue codes, e.g. CPT, HCPC, ICD-9, ICD-10, CMS-1500, UB-04.
    • Managed care concepts and payment methodologies, including claims, reimbursement principles, fee-for-service, capitation, per diem, and DRGs.
    • Configuring practice management system for claims payment, preferably for shared risk model.
    • Medicare/Medi-Cal managed care benefits, fee schedules, guidelines, regulations and data requirements.

    Grade: M

    CB

  • Qualifications
    • Develop and maintain thorough knowledge of data sources used for reporting.
    • Develop and maintain knowledge of CalOptima’s lines of business and health networks.
    • Perform in-depth root cause analysis and develop solutions to complicated issues.
    • Effectively translate business requirements into technical specifications.
    • Work independently and as part of a team under minimal supervision.
    • Develop and maintain effective, productive working relationships with all levels of staff.
    • Work on complex projects and perform data quality analysis.
    • Present information in a useable format and clearly explain the content.
    • Prioritize tasks and schedule work deadlines.
    • Communicate clearly and concisely, both verbally and in writing.
    • Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel and Access - advanced) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.