DescriptionPeaceHealth is seeking a Payer Program Specialist - Care Mgmt for a Full Time, 1.00 FTE, Day position. The salary range for this job opening at PeaceHealth is $23.80 – $35.70. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc.Job SummaryResponsible for the analysis and coordination of risk assessment and population health measures as identified within multiple payer incentive and value-based care contracts. Reviews health records for specified patient populations to ensure accurate and up to date information within the EHR and payer portals. Collaborates with internal departments, clinical teams and external organizations to identify and implement workflows that support the organization in meeting quality targets. Serves as a subject matter expert with knowledge of all current incentive contracts and included measures. Work is generally performed independently requiring judgment and problem-solving skills with limited supervision.Essential Functions
Performs statistical and data analysis, benchmark determination, goal setting, written and graphical reports and data presentations of data for population health management programs (HEDIS, Medicare STARS, CCO metrics, quality management/improvement).
Performs chart reviews to ensure all suspect Hierarchical Condition Category (HCC) conditions from payers are evaluated, invalidates if supported by documentation, or abstracts the appropriate ICD-10 code into the EHR for provider review.
Audits charts retrospectively to identify, assess, and monitor use of active HCC codes or diagnosis invalidations as it pertains to Clinical Condition Categories, submitting data to payers through identified platforms.
Provides a positive financial impact to the organization by analyzing incentive potential, monitoring deadlines and bonus thresholds, and prioritizing work for maximum reimbursement.
Serves as the content expert/resource for payer incentive programs which may include new provider orientation, providing education/resources, and ongoing support for providers in relation to evaluating HCC conditions and quality gaps.
Ensures process and formation flow of all population health data. Analyzes impact of data on various quality improvement projects or programs.
Ensures accurate health maintenance data in the EHR, adjusting erroneous information as appropriate for scope of practice and/or communicates to clinic leadership for updates/corrections.
Continuously analyzes workflows and identifies opportunities to better support the providers in meeting quality targets and accurate HCC capture, to include following standing orders for lab or diagnostic testing as appropriate per licensure/scope of practice.
Performs gap analysis of current systems to determine compliance with data reporting requirements.
Collaborates with other departments as necessary to conduct and complete analyses.
Attends internal and external meetings to present analyzed data.
Coordinates work associated with payer incentive and value-based care agreements and delegates to other staff as needed.
Serves as liaison between payer incentive and value-based care partners (payer, vendor or provider) and PeaceHealth.
Performs outreach work to patients on risk stratified health plans to coordinate care services.
Performs other duties as assigned.
QualificationsEducation
Bachelor's Degree Preferred: Healthcare Administration. or related field of study, or equivalent knowledge obtained through a combination of education, training and experience.
Experience
Minimum of 5 years Required: Healthcare or health insurance setting performing registration, back-office support, care management, quality or health analysis.
Preferred: Experience and/or training in revenue cycle (health insurance plans and benefits structures).
Preferred: Experience and/or training in ICD-10 and Hierarchical Condition Category (HCC) conditions.
Credentials
Preferred: Completion of technical training/certification in a related field, such as Certified Medical Assistant.
Skills
Proficient use of computers including Microsoft Office applications including Excel, Access and Word. (Required)
Proficient in working with spreadsheets, querying data, generating reports and developing/delivering presentations. (Required)
Detail oriented and ability to think analytically and perform data analysis. (Required)
Excellent communication skills, both verbal and written. (Required)
Ability to prioritize and coordinate multiple tasks at once. (Required)
Ability to work effectively within a self-directed teamwork environment. (Required)
Ability to work in an independent and remote environment as position may be a hybrid of onsite and remote work. (Required)
Ability to work from home in a secure environment free of distractions with appropriate high-speed connectivity. (Required)
Working ConditionsLifting
Consistently operates computer and other office equipment.
Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.
Sedentary work.
Environmental Conditions
Predominantly operates in an office environment.
Mental/Visual
Ability to communicate and exchange accurate information.
The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.
PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility (https://www.thecaregiver.org/wp-content/uploads/2017/05/PeaceHealth-Statement-of-Commitment-to-Diversity-and-Inclusion-vFINAL.pdf) .For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.PeaceHealth requires a completed Primary Vaccine Series (e.g., 2 dose monovalent Pfizer, Moderna or Novavax series or 1 dose J&J vaccine series) or be Up to Date (receiving the most recent Pfizer/Moderna bivalent vaccine/booster) for COVID-19 vaccination prior to their start date. PeaceHealth has a medical and religious exemption request process for those that are unable to receive the COVID-19 primary vaccine series due to medical/religious reasons. For caregivers that will be working in Oregon there is a personal vaccine exemption form that may be requested.REQNUMBER: 87029