Capitation Processor

Department: Value-Based Care Programs

Employment Type: Full Time

Location: 9700 Flair Drive, El Monte, CA 91731

Reporting To: Silvia Corona

Compensation: $50,000 - $70,000 / year

Description

We are seeking an experienced Capitation Processor to join our team, with a strong background in processing capitation payments across a wide range of payer types, including CMS, Medicare Advantage, and Commercial Payers. The ideal candidate will have expertise in calculating and processing capitation payments for healthcare providers, particularly in value-based care models, including CMS ACO programs, Medicare Advantage plans, and commercial payer agreements. This role is key to ensuring the accurate, timely, and compliant distribution of capitation payments while maintaining strong provider relationships and supporting the overall financial operations of the organization.

Our Values:     

• Patients First
• Empowering the Independent Provider
• Be Innovative
• Operate with Integrity & Deliver Excellence
• Team of One

What You'll Do

Capitation Payment Processing:

•  Calculate, process, and reconcile capitation payments across all payer types, including CMS, Medicare Advantage, and Commercial Payers. 
• Ensure capitation payments are accurate, timely, and compliant with the terms of provider contracts and regulatory guidelines for each payer type. 
• Work closely with payer representatives, financial teams, and provider relations teams to ensure smooth payment operations. 

Payer-Specific Knowledge: 

• Apply detailed knowledge of CMS, Medicare Advantage, and Commercial payer capitation methodologies to accurately process payments. 
• Ensure compliance with payer-specific guidelines, including risk adjustment models, capitation structures, and regulatory requirements. 
• Stay current on updates to payer guidelines, including CMS ACO program changes, Medicare Advantage plan updates, and evolving commercial payer requirements. 

Data Analysis & Payment Reconciliation: 

• Analyze claims, enrollment, and utilization data to accurately calculate capitation payments for each provider. 
• Reconcile discrepancies between capitation payments and member utilization or claims data, collaborating with internal teams to resolve any issues. 
• Investigate and correct discrepancies, including payment errors, adjustments, and underpayments, ensuring that accurate financial records are maintained.

Provider Relations & Communication: 

• Serve as a point of contact for provider inquiries related to capitation payments, ensuring prompt resolution of any questions or concerns. 
• Collaborate with the provider relations team to communicate capitation payment processes, adjustments, and trends, ensuring transparency and building strong provider relationships. 
• Address provider disputes related to payment calculations and work to resolve any conflicts in a timely and professional manner. 

Reporting & Documentation: 

• Prepare and distribute detailed capitation payment reports to internal stakeholders, including finance, compliance, and leadership teams. 
• Maintain accurate records and documentation related to capitation payments for auditing and compliance purposes. 
• Support external audits related to capitation payments by providing requested documentation and explanations.

Process Improvement & Efficiency: 

• Identify opportunities for process improvements in capitation payment workflows, with an emphasis on increasing efficiency, accuracy, and compliance. 
• Work closely with cross-functional teams to streamline payment processing and reporting, helping to reduce administrative burden and enhance provider satisfaction. 

Compliance & Risk Management: 

• Ensure all capitation payments comply with relevant federal and state regulations, including CMS, Medicare Advantage, and Commercial payer requirements. 
• Assist with internal audits and external regulatory reviews by providing necessary documentation, reports, and explanations. 
• Stay informed on industry best practices, payer-specific regulations, and changes in value-based care models to support ongoing compliance.

Qualifications

Experience:

• Minimum of 3 years of experience in capitation processing, with a strong focus on CMS, Medicare Advantage, and Commercial Payers. 
• Experience with CMS ACO programs and other value-based care models is strongly preferred. 
• Prior experience managing provider contracts and capitation agreements for multiple payer types, includ