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Business Analyst, Sr.
Department(s): Provider Data Management Services
Reports to: Manager, Provider Data Management Services
FLSA status: Non-Exempt
Salary Grade: L - $77,000 - $109,000
The incumbent will be responsible for reviewing and monitoring Facets system provider pricing for provider record. Individual will work with various departments to ensure that system pricing is correctly attached to provider records for claims adjudication and per expected contracted rate. The incumbent will monitor end-to-end claim pricing to identify, report and track potential issues that could affect contract pricing output. Responsible for data reporting and analysis functions for Provider Data Management Services including developing, designing, and maintaining databases. Produce ad hoc reports as necessary in response to requests by senior management and the Board of Directors and as required by the Department of Health Care Services (DHCS). Provide data reports in support of major CalOptima initiatives such as line-of-business expansion.
• Understand the Health Network capitated Division of Financial Responsibility (DOFR) documents by program type and contracting financial models to be able to answer questions from multiple internal departments.
• Understand the different contracting financial models used by CalOptima and how they are applied. This includes Fee for Service (FFS) and capitated/delegated models: Shared Risk (IPA), Hospital, Restricted Knox-Keene, and Knox-Keene.
• Work closely with IS Application Management for each program type and contracting financial models.
• Aids internal departments to triage pricing outcome inquiries.
• Reviews provider contracts for material pricing changes and if needed formally communicate request to IS Application Management for new Facets agreement ID.
• Provides provider pricing information to Provider Data Management Services for provider record.
• Works closely with internal departments for input on improvement and efficiency opportunities related to provider data.
• Develops and maintain desktops procedures relating to reviewing and monitoring Facets system provider pricing for provider records, triaging pricing outcome inquiries, and overall internal department communication procedures for material pricing changes.
• Maintains a database with reporting capabilities for tracking Facets agreement IDs for the provider records.
• Serves as business lead to IS Application Management, Claims and other internal departments for overall pricing related to the provider record, DOFR inquiries, and Facets agreement ID.
• Develops back-end quality control reports to identify any pricing inaccuracies and perform quality assurance review on PDMS Coordinator new Facets agreement ID entries.
• Designs or requests reporting needs from business applications/systems as needed to maintain data integrity.
• Maintains a thorough knowledge of CalOptima's DHCS and/or CMS data reporting requirements and produces reports for DHCS accurately and on a timely basis as it relates to subcontract network certification.
• Other projects and duties as assigned.
Possesses the Ability To:
• Critically think, identify, and perform in-depth root cause analysis and develop solutions to complicated issues.
• Work on complex projects and perform senior-level data quality analysis.
• Effectively translate business requirements into technical specifications.
• Communicate and present information in a clear and concise manner both verbally and in writing.
• Work independently and as part of a team with minimal supervision.
• Prioritize tasks and use time efficiently.
• Utilize and access computer and appropriate software (e.g., Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems (e.g., Facets, MS Access, and GeoAccess) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.
Experience & Education:
• High school diploma or equivalent required.
• 3+ years of data analyst experience in the health care industry required.
• 3+ years of experience working in a health care background or managed care environment required.
• Bachelor's degree in Health Care Administration, Business Administration, or related field, and/or combination of education and experience that would provide the knowledge and skills listed (i.e., data reporting and developing, designing, and maintaining databases) preferred.
• Medicare and Medi-Cal experience preferred.
• SQL and VBA.
• MS Access to create ad hoc reports and design databases.
• GeoAccess to develop reports to analyze provider accessibility.
• Managed care concepts.
• Medicare/Medi-Cal guidelines, regulations, and data reporting requirements.
EEO Statement: CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
ADA/Accommodation Statement: If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations with 72-hour notice by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
To apply, visit https://apptrkr.com/2358565
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