JOB DESCRIPTION
Your Role

The Medi-Cal Encounter Submissions team within Finance Department . The Risk Adjustment Consulting, Senior will report to the Medi-Cal Encounter Submissions Manager. In this role you will provide essential support to all functions within the team including: (1) Encounter data submissions for all lines of businesses in accordance with regulatory requirements and contracts provisions. (2) Provide business logic and verify system processes are in line with the given business rules. (3) Support various projects to completion ensuring timely and accurate implementation. (4) Optimize existing processes to support department priorities.

Your Work

In this role, you will:

• Actively learn the core principles of decision analytics with knowledge of the analytic tools and techniques that are used to acquire and analyze data for reporting and decision making
• Understand, update, and run programs that applies to decision analytic techniques
• Understand claim, premium, membership and/or risk score assignment data at a basic level
• Compile and categorize data, documenting and verifying the factors used in computations such as those used in premiums, benefits, member risk data and score submissions and establishing rating and pricing levels
• Participate in the development and implementation of process of company's projects involving departmental or cross-functional teams focused on delivery of new or existing internal/external programs and/or products
• Have oversight of daily encounter data operations, including running established programs, creating and testing programs, end-to-end monitoring, and reconciliation of regulatory submissions

• Analyze, report submission trends, monitor KPIs, perform root cause analysis and provide solutions to encounter data submission quality, volumes, and timeliness measures

• Work with various stakeholders and industry experts to stay current with regulatory reporting requirements and implement best-in-class submission practices and requirements optimize the processes and submissions

• Ensure workflow procedures and guidelines are clearly documented, communicated and followed

• Support all functions in the department to align with the enterprise priorities and goals. This may include ad-hoc requests and reporting associated with encounter data.
  

Your Knowledge and Experience

• Requires a bachelor’s degree or equivalent experience

• Requires excellent interpersonal, verbal, and written communication and presentation skills – especially presentations of complex, technical information to non-technical audiences and from non-technical information to technical information

• Requires a proactive problem solver with minimal supervision and ability to multitask.

• Required experience with SQL / SAS / Tableau and other data/analytic tools

• QUALIFICATIONS
  Desired experience in healthcare management and state and federal regulatory data standards and requirements

• Desired experience with data reconciliation, control reports and EDI transactions specifically 837P, 837I, 837D, NCPDP 4.2, 277CA, and 999
  

Pay Range:

The pay range for this role is: $ 96800.00 to $ 145200.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

ABOUT THE TEAM
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – join us!

Our Values:

• Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain an accommodation within 30 days, your offer will be rescinded.