PACE Business Office Analyst

Description of Primary Responsibilities:

1. Prescription Drug Events and Risk Adjustment Processing: Review prescription drug events and risk adjustment processing with the Program Director and Medical Director.
2. Enrollments: Assures enrollment of new participants in Medicaid and Medicare systems. Review the MMR (Monthly Membership) report and address any issues. Verifies eligibility of potential enrollees. 
3. Insurance/Revenue: Directs the application processes for Medicare and Medicaid to ensure participants receive the full benefits to which they are entitled. 
4. Claims Processing: Ensures accurate and timely record keeping for necessary elements to bill correctly and ensures validity and accuracy of accounts payables incurred at the PACE center. This includes:
   • Monitoring the electronic capture of TPA details in EMR. 
   • Providing training for PACE staff regarding the process necessary for claims adjudication:
     • Enter authorization of service. 
     • Schedule the service.
     • Deliver the service/enter the delivery in the EMR.
     • Gather results/documentation of the service in the EMR. 
   • Gathering invoices from members billed by providers, contacting providers with authorization and billing info, investigating unauthorized claims, resolving discrepancies, and developing plans to improve processes as needed. 
5. Finance: Coordinates with the FHCN Finance Department on the CMS 1/3 financial audit by organizing collection and analysis of all required data and interfacing with the CMS audit team to ensure smooth operation of CMS visit. Implements corrective action plans for any issues identified during the audit.
6. Compiles data for the annual bid process to ensure proper payment from Medicare Part D services.
7. Respond to monthly financial reports provided by corporate accounting and track trends in fiscal data month to month and year. Makes recommendations regarding any budget variances. 
8. Manages insurance, auto claims process, and gas cards for the Transportation Department.
9. Maintains all vendor contracts to ensure proper service delivery for all participants and correct compensation to all vendors. 
10. Ensures contractor credentialing, OIG and Exclusion monitoring, and vendor compliance with contractual requirements according to PACE regulations.
11. Communicate with vendors and providers regularly regarding PACE updates, quality improvement activities, and other organizational requirements.
12. Maintains the confidentiality of all company procedures, results, and information about participants, clients, or families.
13. Participates in continuing education classes and any required staff and training meetings.
14. Performs other duties as required or requested.
15. Contributes to the program's mission and goals and meets the requirements of the Board of Directors, Bylaws and Rules, Regulations, and other applicable federal, state, and local regulatory and accrediting agencies.

Description of Primary Attributes

Professional & Technical Knowledge:

1. A bachelor’s degree in finance is required. 
2. Experience in management/leadership positions in a business office or healthcare setting.
3. Desire to work in a healthcare environment with a frail elderly population and their families.
4. Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
5. Computer literacy is required. 
6. Knowledge of medical terminology preferred.
7. BLS Certification.
8. Techniques of project management, quality, and research methods.
9. Culture and needs of the socially and ethnically diverse population FHCN PACE serves, health care, systems, and managed care principles and practices.
10. Medicare and Medi-Cal benefits and regulations.

Technical Skills:

1. Work independently and as an influential member of a team.
2. Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, members, providers, and the public.
3. Communicate verbally and in writing effectively with individuals from varying cultures and backgrounds. Prepare concise and clear reports.
4. Identify pertinent policy issues; develop strategies, solutions, and procedures.
5. Organize and track numerous and diverse activities, timelines, and issues.
6. Motivate and lead various participants at all levels in the organization.
7. Use computers effectively to process appropriate data and information and prepare reports.
8. Effectively utilize computer and appropriate software and interact with FHCN PACE Information