Location: San Diego
St. Paul’s is the leading provider of caring senior services since 1960. We are centrally located in the beautiful community of Bankers Hill, close to downtown San Diego. St. Paul’s strives to be the most outstanding and innovative senior home and service provider in California. We are dedicated to serving the physical, spiritual and social needs of the elderly and community, fostering a culture of diversity and inclusion within the highest quality facilities, health care and programs consistent with affordable costs.
JOB SUMMARY: Under the supervision of the Executive Director, oversees and manages the daily functions of St. Paul’s PACE Health Plan insurance related responsibilities for all sites of the St. Paul’s PACE program. Ensures compliance with all Medicare and Medi-Cal health plan regulations and directives, including Part D Fraud, Waste and
Abuse (FWA) and collaborates with the PACE Compliance Officer to ensure implementation of PACE Compliance Plan. Oversees Insurance Eligibility staff, and ensures personnel are trained to perform their functions within the organization. Coordinates with Finance department, contracted services, and PACE staff to ensure provider invoice adjudication, accurate authorization and verification process, ICD10 Code submission and timely reinsurance processing. Oversees encounter data collection, tracking, and reporting to State, CMS, local licensing agencies, and CA PACE Association.
QUALIFICATION AND REQUIREMENTS:
Education: Bachelor’s Degree in business administration, or a health or human services field, or RN degree/diploma preferred. A combination of education and related job experience will be considered.
Experience: A Minimum of five years of experience working in the healthcare field or within a regulatory government agency performing duties involving the oversight of healthcare, and a minimum of three years of supervisory experience.
Skills and Knowledge:
- Ability to lead and supervise effectively.
- Excellent written and verbal communication skills with ability to maintain accurate records.
- Ability to make objective, effective decisions.
- Ability to foster collaborative working relationships.
- Working knowledge of quality improvement and cost containment
- Ability to apply creative problem-solving skills to complex issues.
- Ability to plan, prioritize and follow-up on/delegate responsibilities.
- Data collection skills and knowledge of basic statistical principles.
- Knowledge of electronic medical record systems and related
information technology standards.
PHYSICAL DEMANDS AND WORKING CONDITIONS:
Physical Requirements: Shall be in good mental and physical health, and capable of performing assigned tasks. Requires standing, walking, occasional pushing and pulling, and lifting. Requires the ability to lift up to 50 pounds. Requires manual and finger
dexterity and eye-hand coordination.
Visual, Hearing and Communication Requirements: Requires corrected vision and hearing to normal range, with or without
reasonable accommodation. Must be able to communicate verbally with all staff, caregivers, participants, and community at large.
Pressure Factor: Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Moderate pressure to meet scheduled appointments.
Subject to people that may have the potential for verbal or physical
Environmental Conditions: May be exposed to a risk through contact with toxic substances, communicable diseases and other
conditions common in a health care environment. Subject to unpleasant odors.
DUTIES AND RESPONSIBILITIES:
- Direct, supervise, and evaluate the performance of the Insurance Specialist., Eligibility Specialist, and Health Plan Specialist.
- Coordinate and engage in PACE responsibilities related to Medicare, Medi-Cal, and all other insurance company regulations.
- Keep current with all regulatory bodies regarding health plan
regulations and expectations.
- Develop and maintain effective processes for maintaining participant insurance eligibility, resolving eligibility issues, and timely monitoring of eligibility data to ensure participants maintain benefits that they are eligible for.
- Oversight, monitoring, and auditing of compliance with disenrollment procedures. Provide orientation and ongoing training to PACE staff who have roles in completion of disenrollment process.
- Accountable to implement PACE Compliance plan in collaboration with the Compliance officer, to ensure practices are within the guidelines and regulations of State and CMS Agencies. Ensure compliance with Medicare Part D guidelines and guide operations to detect, correct and prevent fraud, waste and abuse according to the requirements of the compliance plan 42CRF&423.504(b)(4)(vi).
- Monitor, audit, and ensure implementation of written policies, procedures and standards of conduct to ensure St. Paul’s PACE commitment to detect, correct and prevent FWA.
- Responsible for the training and education related to detection, correction, and prevention of FWA to St. Paul’s PACE employees, subcontractors, and any other appropriate entities. Ongoing will promote disciplinary guidelines and standards through a variety of
- Attend CMS and DHCS webinars, CalPACE health plan related
workgroups, National PACE Association (NPA) calls/webinars and other relevant trainings regarding Medicare Part D, FWA, , and health plan management operations. Collaborate with Compliance Officer and Executive Director to implement changes as mandated or recommended.
- Monitor, review and ensure follow up of applicable HPMS memos
applicable to the PACE program.
- Act as a liaison with contracted Pharmacies and/or Pharmacy Benefit Manager to ensure Part D compliance.
- Develop and implement Encounter Data Reporting processes to meet Federal, State, and local regulations for data collection and risk
adjustment rate setting. Keep current on all required data submission processes, attend relevant trainings and workgroups, develop procedures, train appropriate staff, and monitor for compliance and accuracy.
- Ensure that St. Paul’s PACE extracts, reports and tracks data
submitted for mandatory regulatory reporting requirements and as
requested per executive directives.
- Ensure Information Technology systems (including
electronic medical records and information exchanges) are managed and maintained for Center operations for accurate health plan data collection, and efficiency of data collection for regulatory report submissions.
- Ensure that the Adjudication Process is followed in a timely manner for Invoices for services provided to participants. Develop and coordinate processes with contracted services involved in adjudication and payment of PACE invoices.
- Develop and coordinate processes with contracted services involved in Risk Adjustment process, including ICD 10 Coding and code
- Track and complete qualifying claims through the re-insurance
- Assist in program development and preparation of St. Paul’s PACE short-range and long-term plans, related budgets and information
systems based on broad organization goals and growth objectives.
- Participate in quality assurance/quality improvement initiatives and committees as part of the overall quality improvement program.
- Active member of PACE Leadership Team per QI Program
- Perform related duties as required.
Reports To: Executive Director
If you prefer to fax your application and resume you may fax it to 619.239.1256. We also accept applications in person at 328 Maple Street, San Diego, CA 92103. Come to the 2nd floor and let the receptionist know you would like to complete an application.
To apply online, please visit www.stpaulseniors.org.
YOU MUST BE ABLE TO CLEAR FINGERPRINTS THROUGH DOJ AND FBI IN ADDITION TO A DRUG SCREEN CLEARANCE.
St. Paul’s Senior Services is an Equal Opportunity Employer