Health Plan Specialist

Ultimate Staffing; Modesto (CA); On-site; USD 33,000 - 34,000; Full time

Job summary

Ultimate Staffing Services is seeking a Health Plan Specialist in California to support health plan operations through data analysis, compliance, and documentation updates to meet regulatory requirements. This onsite role involves collaborating with CMS, DHCS, and cross-functional teams to ensure accurate reporting and adherence to policies.

Ideal candidates will have at least two years of experience in claims processing, contracting, and compliance, with strong Excel and MS Office skills.

Qualifications

• Two years of experience in claims processing, contracting, compliance, or related fields.
• CMS and HPMS IT familiarity preferred.
• Associate degree in business or healthcare administration or equivalent work experience.

Responsibilities

• Assist in CMS and DHCS compliance efforts and contract adherence.
• Prepare Medicare/Medicaid cost reports and related documentation.
• Manage inquiries to CMS and DHCS with timely responses.
• Analyze data to support decision making and trends.
• Prepare reports on Medicare and MediCal reporting and reimbursement.
• Support closing processes for Medicare and MediCal payments.
• Develop and maintain SOPs to comply with regulations.
• Ensure marketing materials comply with CMS regulations.
• Coordinate with geriatric patients including cognitive decline when needed.
• Submit regulatory reports to CMS and HPMS as required.

Skills

Analytical skills

Team collaboration

Education

Associate degree in business administration or healthcare administration

High School Diploma or equivalent

Tools

Excel

MS Office

Relational database modeling

Job description

Salary: USD24 - USD25 per hour

Position Overview

Ultimate Staffing Services is actively seeking a dedicated Health Plan Specialist to join their client's team in California. This role focuses on supporting health plan operations through data analysis, compliance efforts, and collaboration with various departments to ensure seamless health plan processes. The ideal candidate will be instrumental in maintaining and updating health plan policies, procedures, and documentation to adhere to regulatory requirements.

Responsibilities

• Assist Central Valley PACE Quality and Compliance efforts to ensure health plan compliance with CMS and DHCS contracts.
• Prepare Medicare and Medicaid cost reports and related documentation as per regulations.
• Manage inquiries and submissions to CMS and DHCS, ensuring timely responses.
• Perform analysis to support decision-making based on outcomes and impacts.
• Prepare reports related to Medicare and MediCal reporting and reimbursement.
• Support periodic closing processes concerning Medicare and MediCal payments.
• Identify and interpret trends in complex data sets accurately.
• Develop and maintain Standard Operating Procedures to comply with legislative requirements.
• Ensure health plan marketing materials comply with CMS regulations.
• Assist in preparing the Health Plan for regulatory audits and report potential compliance issues.
• Interact professionally with geriatric individuals, including those with cognitive decline.
• Maintain regulatory reporting structure and submit documents to CMS as required.
• Coordinate benefits, manage medical appointments, and organize medical records for PACE participants.
• Handle other projects and duties as assigned.
• Maintain a safe work environment, following necessary precautions when lifting or transferring patients.

Qualifications

• Valid California Driver’s License with an acceptable driving record and vehicle insurance.
• Bilingual in English and Spanish is preferred.
• Current BLS CPR Card certified by the American Heart Association or American Red Cross.
• Strong analytical skills and the ability to collaborate effectively in a team environment.
• Proficient in Microsoft Office applications, with advanced Excel skills required.
• Relational database and financial or operational modeling experience preferred.

Education/Experience

• High School Diploma or equivalent required.
• Associate degree in business administration, healthcare administration, or related field, or two years of equivalent work experience.
• Familiarity with CMS and HPMS information technology is preferred.
• Minimum of two years of experience in claims processing, contracting, compliance, credentialing, billing, and coding.

Work Hours

Monday to Friday, 1st shift.

The position offers competitive pay with a salary range of $24.00 to $25.00 per hour.

This position is 100% onsite in California, ensuring a comprehensive and collaborative working environment.