Responsible for assisting Health Plan Manager in providing oversight and coordinating the daily operations of health plan objectives including contracts, compliance, credentialing, communication, authorizations/claims, and disputes in a manner that meets established turnaround, quality and production goals, and regulatory standards. In the absence of the HP Manager, AHP Manager will act as HP Manager.

Schedule is Monday – Friday, 8am – 5pm.

Duties and Responsibilities

• Identify opportunities to the health plan network by evaluating existing relationships and establishing new relationships.
• Contracting with providers and health delivery organizations from inception to completion.
• Developing relationships with contracted third part administrators and other first tier, downstream and related entities (FDR’s).
• Evaluating Parts A, B, and D Medicare and Medi-Cal health plan functions and reporting to the Health Plan Committee.
• Responds to and resolves or facilitates resolution of complex issues including enrollments/dis-enrollments, authorizations/claims, appeals, provider disputes, and third party liability cases.
• Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
• Plans and assigns work, monitors department workload to ensure mandated turnaround times are met, makes timely and effective adjustments.
• Maintains department policies.
• Monitors communications with the California Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS).
• Assists with the development and implementation of department-related upgrades and enhancements of transaction system and other tools.
• Identifies, monitors and analyzes transaction system processing issues; corrects and/or escalates as required.
• Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required.
• Prepares for and participates in regulatory audits: compiles audit packets, provides information, develops and monitors timely and effective corrective action plans.
• Executes and monitors business plans; assists in the development and monitoring of department budget and objectives.
• Promotes and maintains an environment that supports GVHC’s strategy, vision, mission and values.
• Assist with the hiring, supervision and training of staff.
• Other duties as required.

Physical Demands

• Ability to lift up to 30 pounds. Moving, lifting or pushing greater than 30 pounds, should be done with assistance as appropriate.
• Must be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
• Must have vision with or without lenses that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
• Must have high manual dexterity.
• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.

Work Environment

Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment. Subject to unpleasant odors. The noise level is usually quiet to moderate, but may at times be noisy and crowded.

Education/Experience Requirements

Minimum Qualifications

• Valid California Driver’s License, acceptable driving record and vehicle insurance.
• Bilingual English / Spanish preferred.
• Proven analytical ability, problem solver, collaborate well in a team environment and demonstrate the ability to learn quickly.
• Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
• Relational database and financial or operational modeling experience preferred.

Education/Experience

• Bachelor's Degree in Business, Accounting, Finance, or related field is preferred.
• Current BLS CPR Card certified by the American Heart Association.
• Minimum two (2) years Health Plan processes, compliance, and reporting experience required.
• Minimum one (1) year of supervisory experience.