Job Abstract

Job ID

2024-3872

# of Openings

1

Category

Directors & Executives

Type

Full-Time

Min

USD $84,885.00/Yr.

Max

USD $106,228.00/Yr.

Planned Parenthood of Orange and San Bernardino Counties has a full-time opportunity for a Senior Payor Transformation Analyst – HEDIS/Quality Measure in Anaheim, CA.

The Senior Payor Transformation Analyst will report to the Director of Performance Improvement and Project Facilitation and assist in ensuring Melody Health’s successful transition to a value-based care model. This analyst will lead and manage Healthcare Effectiveness Data and Information Set (HEDIS) and quality performance projects and workflows. Key tasks for this analyst include identifying opportunities for internal process improvements to enhance/maintain quality scores and coordinating workflows with internal departments. This individual will bridge multiple departmental and health plan criteria to efficiently meet all benchmark and performance standards. This position will be a resource to Contracting, Revenue Cycle Management, Operations, Quality, Case Management and Clinical leadership in executing and enhancing Melody Health quality performance metrics.

At PPOSBC, we understand the importance of a well-rounded benefits program and are dedicated to providing you with unique benefits that meet the needs of you and your family. We are proud to offer a range of plans that help protect you in the case of illness or injury including:

• A competitive benefits package includingl: medical, dental, and vision coverage for you and eligible dependents, life insurance, and long term disability.
• Benefits coverage starts after one full month of employment!
• Generous vacation, sick, and holiday benefits!
• Generous 401(k) matching contributions and more!
• To view our detailed benefits guide, please visit our career site at www.pposbccareers.org

Minimum Education:

• Bachelor Degree required or 5 years’ experience in lieu of degree

Minimum Work Experience:

• 5-7 years’ experience in a healthcare related field; payor relations, managed care, ambulatory clinic, revenue cycle management, etc.
• 3-5 years’ experience working with health plans, payor industry or managed care (HMO, PPO, Medi-Cal, Covered CA, etc.)
• Primary care, preferred, with clinical experience being a plus
• Experience in quality programs, NCQA, STARS, CAHPS, Pay-for-Performance

Additional Qualifications:

• Demonstrated ability as an effective leader including coaching and team-building skills.
• Strong written, verbal and interpersonal skills.
• Must be self-motivated and have the ability to work without direct supervision.
• Proficient in data manipulation and working with data.

Agency Standard Requirements:

• Strong commitment to quality healthcare and excellent customer service is required.
• Must thrive in a fast paced, rigorous environment with changing priorities.
• Ability to meet deadlines and work under pressure.
• Must demonstrate high level computer skills including; Microsoft Word, Excel and Outlook. Electronic medical records experience may also be required.
• This position may require travel to other sites and locations; if using a personal vehicle to meet this requirement, a valid CA driver’s license and current auto insurance in compliance with the minimum requirements of CA vehicle code are required.
• Abortion patients are cared for at each of our health centers and in part through the administrative, support, and other non-clinical services provided at all PPOSBC locations and by all PPOSBC employees, and supporting these critical services is an essential job duty and fundamental responsibility of all employees.

Essential Functions: Essential functions encompass the required tasks, duties and responsibilities performed as part of the job and the reason the job exists.

Health Plan/Managed Care

• Attend all relevant Health Plan meetings, trainings, webinar, etc. regarding plan updates, quality scoring, new contract requirements, quality measures, etc. Communicate vital information back to departments with any recommendations/concerns
• Liaison and address any health plan, provider or departmental questions with exceptional professionalism and diligence
• Informs and leads discussions with internal departments of contract changes, requirements or recommendations and facilitates the development of operational processes to align Melody Health’s Primary Care Division with payor requirements
• Review, investigate and address payor inquiries and complaints and escalate complex matters to appropriate leaders
• Coordinate JOM, Quality, or other meetings between internal and external stakeholders

Quality/HEDIS Measure

• Monitor, review and manage reports of all HEDIS, utilization, P4P and any other quality program related activities and performance benchmarks.
• In collaboration with internal stakeholders works to ensure compliance with all quality related activities, not limited to HEDIS, NCQA, Utilization, etc.
• Manage opportunities for internal process improvements to quality scores in collaboration with PIO Director
• Collect and analysis revenue cycle, payor, quality and other relevant data sources in order to improve quality performance workflows and processes. Recommend action items based on data review.
• Partner closely with cross functional teams to include Quality, Data Analytics, Contracting, Informatics, Revenue Cycle Management and other departments as applicable to liaison alignment in quality improvement workflows
• Stay informed of payer industry market trends and industry leading practices for quality programs

Administration

• Manage and store health plan manuals and contracts as applicable
• Partner with departments and subject matter experts both internally and externally in order to facilitate collaboration under the direction of PIO
• Develop and lead monthly payor meetings with organization leadership and executives including but not limited to maintaining the agenda, tracking logs, minutes and follow up activities as a result of meeting conclusion
• Lead projects/initiatives under the direction of the PIO

Non-Essential Functions:

Other duties as assigned.

CORE COMPETENCIES – WE CARE:

• Welcoming: Anticipates customer requirements and gives high priority to customer satisfaction and service. Handles problems quickly and efficiently. Maintains a pleasant, positive and professional approach. Embraces opportunities to help team members, stakeholders, and other departments.
• Equitable: Creating equitable access and opportunity for all through education, practicing inclusive behavior, elevating others’ voices, creating spaces for honest conversation, and listening without judgment. Values and uplifts our collective diversity within in our agency.
• Confidential: Respects the information shared by our patients, employees, and vendors and maintains appropriate confidentiality. Follows all policies and laws that protect private & privileged information.
• Accessible: Is available and approachable to others, open-minded, fair and non-defensive. Appreciates constructive feedback and is a team player. Demonstrates good listening skills.
• Respectful: Values diversity and treats everyone with dignity and courtesy. Dependable and courteous of other people’s time and commitments.
• Empathetic: Demonstrates interest and understanding in other people’s feelings, attitudes and reasoning. Maintains an open and non-judgmental demeanor that is patient, flexible, and understanding.