This position requires analysis of network adequacy, access and availability, and reporting findings within PacificSource and to external entities including CMS, NCQA and OHA. Responsible for auditing contract allowables, configuration and provider setup within Facets. Ensure findings are corrected and documented for reference within OnBase, Sharepoint and other tracking sources. Identify additional audit opportunities and necessities throughout Provider Network. This position requires a high level of accuracy, communication, attention to detail and accountability.
Work Experience: Three years of experience with a payor and/or provider in healthcare reimbursement, audit and reporting. Experience with government reporting and data submissions preferred. Advanced experience with spreadsheets and analytic experience required.
Education, Certificates, Licenses: High school diploma required.
Expert spreadsheet modeling and analytical ability essential. Fast and accurate data entry skills. Extensive knowledge of medical and insurance industry. Extensive knowledge of PacificSource claims system and contracting methodologies. Expert understanding and knowledge of all policies and procedures within Provider Network. Ability to prioritize work. Organizational skills. Self-motivation. Effective written and oral communication, including diplomacy skills for working with the medical professional community as well as the members enrolled in a PacificSource plan.
Responsible for each new and existing contract audit. Responsible to assist with annual regulatory reporting, and monitoring. Responsible for providing prompt, courteous customer service to PacificSource personnel and all outside contacts. Support PacificSource decisions by being consistently helpful, confident and pleasant while working with a wide variety of personalities.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.