Compliance Data System Support Specialist - 25-160

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees.  We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Under the direction of the Manager, Compliance Data System Support (CDSS), Compliance Data Support Specialist (CDSS) works with the Compliance Staff and operational areas and Information Systems (I.S.) to provide support in the management of auto- adjudication rules, configuration, mapping, and interface business logic within these applications, and provide reporting on an ad hoc basis for management and staff. Also provides support for system applications, processes, regulatory scheduled Utilization and Claim reporting that require coordination between various departments. The purpose is to improve the overall quality and efficiency of services for our members and providers. Monitor clinical and claim operations to ensure that delegated regulatory reporting is compliant with health plans and federal, and state regulations. The Compliance team is expected to schedule, facilitate, and document meetings to support business needs with the managed applications.

ESSENTIAL RESPONSIBILITIES:

Reporting

• Produce and customize regulatory reporting requirements of health plans to meet their report needs and ensures accurate data and timely delivery.
• Create standardized and proprietary reports according to contractual, regulatory, and/or technical requirement specifications.
• Develop and/or Monitor data validation tools and processes.
• Perform data validation procedures to ensure accuracy in reporting.
• Generate and validate scheduled reports before delivery to health plans and/or regulatory agencies.
• Maintain schedule of required reports to ensure timely delivery.
• Identify departments, businesses, technical owners impacted by report requests.
• Distribute report-related information and recommend tasks to identified report team members.
• Coordinate and chair report team meetings for new and ongoing requirements with applicable teams.

• Establish report delivery method, coordinate STFP, TLS, or Secure email.

Compliance/Audit Support

• Review and validate new and or enhanced Health Plan and regulatory agency reporting requirements.
• Coordinate communication with Health Plan to clarify reporting requirements.
• Review new/amended delegation agreements with Contracting.

System Requirements and Testing

• Participate in system implementations, upgrade, and enhancement projects.
• Coordinate, assign, and complete report testing plans in the development, implementation, and upgrade process.
• Quality Assurance is performed at a high level to assess immediate reporting impacts and report the outcomes.
• Assess the need of developing new operational processes for new products, develop or revise existing processes, and work with relevant departments to ensure that implementation and testing of systems are complete and meet regulatory reporting requirements.

Project Coordination, Process Improvement & Compliance Monitoring

• Collaborates and communicates with various customers, vendors, and internal departments/teams to improve the quality of data and information workflows.
• Act as the liaison between internal business units, and health plan partners, to assist with the coordinating interdepartmental workgroup meetings.
• Collaborate with Business units in developing monitoring reporting tools that help guide business decisions.
• Research and reconcile data discrepancies occurring among various information systems and reports.
• Participate in and improve