_PEOPLE.PASSION. PURPOSE. _

At P3 HealthPartners, our promise is to guide our communities to better health, unburdenclinicians, align incentives and engage patients.

We are aphysician-led organization relentless in our mission to overcome all obstaclesby positively disrupting the business of health care, transforming it fromsickness care into wellness guidance.  

We are lookingfor a UM DATA VALIDATION SPECIALIST.  If you are passionate about your work; eagerto have fun; and motivated to be part of a fast-growing organization in LasVegas, Nevada, then you should consider joining our team.

OVERALL PURPOSE:

The UM Data Validation Specialist is responsible for working with all programs within the Medical Management (MM) department and works closely with internal and external stakeholders in data analysis, reporting, and UM and CM system programming. This individual will be engaged in Utilization Management (UM) and Care Management (CM) process workflows and maintains extensive knowledge of the electronic systems and reporting. The position is responsible for implementing auditing systems, to detect and track errors in data, identify opportunities for improvement, and root cause analysis to recommend and implement solutions. Additionally, the UM Data Validation Specialist is responsible for reducing risk and searching for potential issues. The UM Data Validation Specialist must be forward-thinking and innovative to collaborate with different departments and streamline processes.

The Medical Management Department encompasses Utilization Management, Quality Management, and Care Management.  The Utilization Management department process prior authorizations as dictated by but not limited to the following: Centers for Medicare and Medicaid Services (CMS), the National Committee on Quality Assurance (NCQA), and respective health plans.

KEY RESPONSIBILITIES:

• Implementing auditing systems

• Identify opportunities for improvement and root cause analysis

• CMS Part C ODAG reporting and audit

  • Weekly internal ODAG data review and research of out of compliance or cases missing data

  • Monthly Part C ODAG audit, preparation and health plan live audit of system vs. ODAG

  • Quarterly Part C reporting

    • Line item review and manual updates to correct data pull into ODAG

    • Tracking gaps to collaborate with Director of MM to advise Analytics

• Monthly Withdrawn audit, preparation and live health plan audit

• Work with analytics to correct missing data

• Review and respond to Health Plan CAP

• SNP reporting

  • Gather monthly SNP reports, review, identify areas for improvement

  • Participate in SNP live audits with CMS

• Internal review of UM and SNP cases- random sample weekly audits

• Assist with policy and standard operating procedure development

QUALIFICATIONS:

• Bachelor’s degree in Database Management or Information Systems or Health Care Administration or another related field

• 2+ years’ experience with CMS Part C Reporting

• Analytical and critical thinking

• Data mining

• Business acumen

• IT skills

• Effective communication

• Project management