Position Summary:

The Senior Analyst, Health Plan operations of the San Ysidro Health's (SYH) San Diego Program for the All-Inclusive Care of the Elderly (PACE). Responsible for overseeing the creation, revision, updating, maintenance and dissemination of Best Use Practices guidelines, policies and procedures.

 

Essential Functions of the Job:

 

 

• Responsible for the development and application of evidence-based medical guidelines and policies and procedures for Best Use Practices, both for internal providers and staff, and for external network, contracted providers and non-contracted providers. Ensures optimal outcomes through an educational program for SD PACE providers and all other IDT members and for both contracted and non-contracted providers.
• Under the direction of the SD PACE Associate Chief Medical Officer and the SD PACE-Health Plan Director. Works closely with the Director of Quality and Compliance to ensure standards are met.

 

• As PACE providers and IDT are responsible for participant care decisions, the Analyst ensures that evidence-based guidelines, and any relevant policies and procedures are in place to support them. The Analyst is also responsible for dissemination of this information through a comprehensive and ongoing education program for providers and IDT members.

 

• For external Providers on contract and in network, as well as those with Letters of Agreements, the Analyst is responsible for their guidelines, policies and procedures including education.

 

• Maintain effective relationships with San Diego PACE PCPs, and IDT members.

 

• Identify, develop and maintain effective relationships with external contracted providers and PACE regulatory agencies.

 

• Manages and trains network providers on provider portal.

 

• Ensures provider issues and concerns are addressed timely by coordinating communication with other PACE departments.

 

• Works with Eligibility team to ensure requirements are updated, maintained, and disseminated.

 

• Educate enrollment team on San Diego PACE's Best Use Practices guidelines, policies and procedures.

 

• Works with the SD PACE Finance Office and claims departments to ensure staff are well versed in the guidelines, protocols and procedures of the Best Use Practices operation.

 

• In collaboration with PACE executive team, keeps current on regulation and policy impacting the PACE program.

 

• Develops guidelines and policies that meet applicable regulatory agency and PACE requirements  and ensures adherence to guidelines, policies and regulations by  developing  dashboards  and related workflows .

 

• Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.

 

• Resolve issues by identifying the problem, examining solution options, implementing an action plan and providing resources.

 

• Oversees program guideline, policy and procedure development to ensure compliance with current industry regulations.

 

• Plan and direct the development and delivery of training and educational programs for all department personnel and external providers.

 

Additional Duties and Responsibilities:

• Maintains and updates established departmental policies and procedures as needed.

 

• Keeps abreast of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government/regulatory agencies.

 

• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.

 

• Attends meetings as required.

 

• Performs other related duties as assigned or requested.

 

Job Requirements

Experience Required:

• (1) year of related experience in at least one of the following: geriatrics, medically fragile, and/or underserviced populations;
• (3) years of related experience strongly preferred.  
• Clinical experience strongly preferred.
• Strong writing, analytical and oral presentation skills.
• Candidate must be comfortable working in a dynamic environment with both short-term and long­ term deadlines.
• Experience with PACE or related programs strongly preferred.

Education Required:

• Preferred: Bachelor's or Master’s degree in business, accounting, finance or health related field.

 

Verbal and Written Skills Required to Perform the Job:

• Excellent written and verbal communication skills.

 

Technical Knowledge and Skills Required to Perform the Job:

• Culture and needs of the socially and ethnically diverse population that San Diego PACE serves.
• Community-based organizations, agencies and community services.
• Principles and practices of health care, health care systems, and managed care.
• Medi-Cal/Medicare benefits and regulations.
• Techniques of program and policy development, administration and coordination.
• Health Plan, Hospital and Medical Group operations and strategies.
• Knowledge and experience working with LTC facilities, SNF, hospice, etc.
• Working knowledge of health care delivery and financing systems, including Medicaid, Medicare, waiver programs, prospective and capitated systems, public health programs, and HMO/Managed Care.
• Good working knowledge of healthcare, social services, and aging networks, as well as relevant federal and state systems.
• Working knowledge of the principles, procedures and techniques governing contract negotiations.

 

Equipment Used:

• PC, Laptop, printers and other equipment found in an office setting. Microsoft Office suite and Excel knowledge strongly preferred.

 

Working Conditions and Physical Requirements:

• Employee must be able to sit for extended periods of time, as well as work at the computer for long periods.  
• Employee must be able to work in an office setting with moderate noise levels and controlled office temperatures.

 

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.