Health Plan Analyst

Piedmont Health Services Inc; North Carolina; On-site; USD 50,000 - 62,000; Full time

Benefits offered by this job

Medical, Dental, Vision, Life

403(b) Plan

Paid Holidays

CME

Job summary

Piedmont Health Services, Inc. in North Carolina is seeking a Health Plan Analyst to ensure contracting and data submission compliance for the PACE program.

The role is office-based at the Corporate Admin Office and follows a Monday–Friday schedule with standard business hours. The analyst will monitor CMS regulations, manage data uploads (HPMS, PDE, P2P), support audits, and liaise with vendors and consultants to ensure accurate, timely information and financial reporting.

Qualifications

• Bachelor’s Degree or a minimum 5 years of experience in a related business environment.
• Requires frequent sitting for long periods, operation of standard office machines and computer. May require lifting up to 25 pounds.
• Preferred: PACE or managed care experience.
• Current/valid License: Valid NC Driver’s License in good standing with personal automobile insurance.
• Immunizations: Be medically cleared for communicable diseases and have all immunizations up-to-date prior to beginning employment.

Responsibilities

• Monitor health plan compliance: Stay current on CMS regulations for PACE sites and data submission; monitor HPMS announcements.
• Ensure accurate tracking and reporting of data in compliance with CMS regulations; upload DataPACE2, PDE files, Plan to Plan (P2P) reconciliation, DIR report and annual financial reports.
• Ensure handling of RAPS data files for Medicare and Medicaid.
• Prepare and submit PDE files and ensure timely development and submission of Part D bid.
• Prepare and submit enrollment files and validate data in HPMS; upload enrollment files and troubleshoot Medicare/Medicaid issues.
• Check the DTRRD daily.
• Serve as primary contact for utilization consultants and external consultants (e.g., Medicare coding and risk adjustment firms).
• Assist with audits; actively manage contract service authorizations for multi-site PACE division with third party administrator.
• Data entry and verification of information, including verification of claims and payments from Medicare/Medicaid.
• Develop working relationships with all contracted vendors and act as conduit for issue resolution.
• Serve as contact for third party administrator for authorization of external service payments.
• Manage Authorization for services including IBNR accuracy, claims adjudication and appeals.

Skills

Regulatory compliance

Data accuracy

Vendor liaison

Education

Bachelor's degree or 5 years experience

Job description

About Piedmont Health Services

Piedmont Health Services, Inc. (PHS) is a 501(c)(3) nonprofit and Federally Qualified Health Center (FQHC) in North Carolina. Dedicated to delivering top-tier, accessible, and inclusive primary healthcare, PHS has proudly served for 54 years and remains the largest community health center in central NC. Operating 10 Community Health Centers, two PACE (Program of All-Inclusive Care for the Elderly) Senior Care facilities, and 2 Mobile Health Units, PHS extends its services to residents across five counties, including Alamance, Caswell, Chatham, Orange, and Lee.

What is PACE?

At Piedmont Health Senior Care, we are dedicated to enhancing the lives of seniors in our community through our Program of All-inclusive Care for the Elderly (PACE). We help seniors maintain their independence and continue living at home for as long as possible. We achieve this by offering comprehensive, personalized healthcare and related services, all tailored to the unique needs and aspirations of each senior we serve.

Our approach is unlike any other healthcare plan! PACE emphasizes a participant-centered strategy, focusing on providing the right care and services that best support each participant's unique needs and goals. We integrate and coordinate all aspects of care, leveraging a team of dedicated doctors, nurses, therapists, dieticians, and other specialized professionals who work together as a care team to manage and address the complete health needs of each.

Job Title - Health Plan Analyst

Department - PACE

Reports to - Health Plan Director

Benefits -

• Medical, Dental, Vision, Life Insurance (Short & Long Term Disability)
• 403(b) Plan
• Paid Holidays
• CME (Continuing Medical Education)

About Position:

The primary responsibility of the Health Plan Analyst is to assure compliance with health plan regulations on contracting (including authorizations) and data submissions.

• Work Location: Corporate Admin Office
• Schedule: Monday - Friday 8:00 am - 5:00 pm
• Travel: N/A

Duties/ Responsibilities -

• Monitor health plan compliance: Remain current on regulations by CMS of PACE sites and compliance with data submission; monitor daily HPMS announcements.
• Ensures accurate tracking and reporting of data in compliance with CMS regulations; upload DataPACE2, PDE files, Plan to Plan (P2P) reconciliation, Direct/Indirect Remuneration (DIR) report and annual financial reports.
• Ensures of the Risk Adjustment Processing System (RAPS) data files for Medicare and Medicaid
• Prepares and submits PDE files and ensures timeliness in development and submission of Part D bid
• Prepares and submits enrollment files and validates data in HPMS
• Upload enrollment files and troubleshoot Medicare/Medicaid issues
• Checks the DTRRD daily
• Serves as the primary point of contact for utilization consultant and for consultants, e.g. the Medicare coding and risk adjustment consulting firm
• Assist with audits as neededActively manage contract service authorizations for multi-site PACE division in collaboration with third party administrator.
• Data entry and verification of a variety of information, including verification and accuracy of claims from vendors and payments from Medicare and Medicaid.
• Develop working relationships with all contracted vendors.
• Act as conduit between organization and contracted vendors to resolve service related issues.
• Serve as contact person for third party administrator for authorization of external contact service payments.
• Manages Authorization for services process, including IBNR accuracy, claims adjudication and claim appeals.

Qualifications -

Education: A Bachelor’s Degree or a minimum 5 years of experience in a related business environment.

Required: Requires frequent sitting for long periods, operation of standard office machines and computer. May require lifting of up to 25 pounds. Requires eye-hand coordination and manual dexterity. Requires the use of office equipment, such as computer terminals, telephones and copiers. Requires normal vision. Work is performed in an office environment. Contact with staff and external clients/vendors.

Preferred: PACE or managed care experience preferred.

Current/valid License: Valid NC Driver’s License in good standing with personal automobile insurance.

Immunizations: Be medically cleared for communicable diseases and have all immunizations up-to-date prior to beginning employment.

Pay Range - $50,306.00 - $61,870.00

EEO Statement

Piedmont Health Services, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to sex, sex stereotyping, pregnancy (including pregnancy, childbirth, and medical conditions related to pregnancy, childbirth, or breastfeeding), race, color, religion, ancestry or national origin, age, disability status, medical condition, marital status, sexual orientation, gender, gender identity, gender expression, transgender status, protected military or veteran status, citizenship status, genetic information, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.