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Senior Analyst, PACE Health Plan Operations - Kearny Mesa/Hybrid - San Diego California
Company: San Ysidro Health
Location: San Diego, California
Posted On: 05/06/2025
Position Summary:The Senior Analyst, Health Plan Operations at San Ysidro Health's (SYH) San Diego Program for the All-Inclusive Care of the Elderly (PACE), is responsible for overseeing the creation, revision, updating, maintenance, and dissemination of Best Use Practices guidelines, policies, and procedures.Essential Functions of the Job: Develop and apply evidence-based medical guidelines, policies, and procedures for Best Use Practices for both internal staff and external providers, ensuring optimal outcomes through education programs for SD PACE providers and IDT members. Work under the direction of the SD PACE Associate Chief Medical Officer and SD PACE-Health Plan Director, collaborating with the Director of Quality and Compliance to meet standards. Ensure evidence-based guidelines and relevant policies support participant care decisions made by PACE providers and IDT, and disseminate this information through ongoing education programs. Manage guidelines, policies, and procedures for external contracted and in-network providers, including education efforts. Maintain effective relationships with San Diego PACE PCPs, IDT members, external providers, and PACE regulatory agencies. Manage and train network providers on the provider portal, ensuring timely resolution of issues by coordinating communication with other departments. Collaborate with the Eligibility team to ensure requirements are current and properly disseminated. Educate the enrollment team on Best Use Practices guidelines, policies, and procedures. Work with the Finance Office and claims departments to ensure staff are knowledgeable about guidelines and protocols. Stay current on regulations and policies impacting the PACE program, developing guidelines that meet regulatory requirements and ensuring adherence through dashboards and workflows. Maintain audit readiness through ongoing training, competency assessments, monitoring, and corrective actions. Identify and resolve issues by analyzing problems, exploring solutions, and implementing action plans. Oversee program guideline, policy, and procedure development to ensure compliance with industry regulations. Plan and direct training and educational programs for department personnel and external providers.Additional Duties and Responsibilities: - Update departmental policies and procedures as needed.
- Ensure compliance with all relevant regulations and standards.
- Participate in educational programs, literature review, meetings, and workshops for professional growth.
- Attend meetings as required and perform other duties as assigned.Job RequirementsExperience Required:
- At least 1 year of related experience in geriatrics, medically fragile, or underserved populations.
- Strongly preferred: 3+ years of related experience and clinical experience.
- Excellent writing, analytical, and oral presentation skills.
- Ability to work effectively in a dynamic environment with short-term and long-term deadlines.
- Experience with PACE or related programs is strongly preferred.Education Required:
- Bachelor's or Master's degree in business, accounting, finance, or a health-related field is preferred.Skills and Knowledge:
- Excellent verbal and written communication skills.
- Knowledge of diverse populations, community organizations, healthcare systems, and managed care principles.
- Understanding of Medi-Cal/Medicare benefits and regulations.
- Experience in program and policy development, administration, and coordination.
- Familiarity with healthcare operations, LTC facilities, and financing systems.
- Knowledge of healthcare, social services, and aging networks, as well as relevant federal and state systems.
- Understanding of contract negotiations principles and procedures.Equipment Used:
- Standard office equipment including PC, laptop, printers, and familiarity with Microsoft Office and Excel.Working Conditions and Physical Requirements:
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