PACE Health Plan Manager (Central Valley PACE - Ceres Whitmore)

The PACE Health Plan Manager is responsible for overseeing the daily operations of health plan objectives, including contracts, compliance, credentialing, communication, authorizations/claims, and disputes. The role involves coordinating with third-party administrators, the California Department of Health Care Services, and the Centers for Medicare and Medicaid Services to ensure compliance with regulatory standards.

Requirements

• Plans and assigns work; monitors department workload to ensure mandated turnaround times are met
• Identifies, monitors and analyzes appropriate metrics; develops timely and effective corrective action plans based on findings
• Develops, implements and maintains department policies and procedures; makes recommendations for revisions
• Facilitates relationships with contracted third part administrators and other first tier, downstream and related entities (FDR’s)
• Monitors communications with the California Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS)
• Coordinates the compliance and fraud, waste and abuse program with direction from the PACE Medicare Compliance Officer and Executive Director
• Responds to and resolves or facilitates resolution of complex issues including enrollments/disenrollments, authorizations/claims, appeals, provider disputes, and third party liability cases
• 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 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
• Identifies training needs and opportunities; develops and delivers routine and ad hoc department training
• Promotes and maintains an environment that supports GVHC’s strategy, vision, mission and values
• Hires, supervises and retains staff
• Oversee outreach, enrollment and marketing
• Assists in developing department objectives and business plans

Benefits

• Generous Paid Time Off
• 401k Matching
• Retirement Plan
• Tuition Reimbursement
• Relocation Assistance