PACE Health Plan Analyst

Location: CHA East Cambridge Care Center 

Work Days: 8:00am - 4:30pm, Monday - Friday  

Category: Professional and Management  

Department: CHA PACE  

Job Type: Full time  

Work Shift: Day 

Hours/Week: 40.00 

Union Name: Non Union

Department Description:
CHA PACE is a Program of All-Inclusive Care for the Elderly (PACE) at Cambridge Health Alliance (CHA). CHA PACE serves adults 55 years and older with chronic medical and/or mental health difficulties with the goals of achieving the highest level of community independence and preventing nursing home placement. CHA PACE's high functioning interdisciplinary team works to fully integrate and coordinate medical and behavioral health care, community resources, and in-home support services. 

Job Summary:
This position supports a variety of PACE health plan operations, including working with a PACE health plan third party administrator (TPA) and its PACE pharmacy benefit manager (PBM) to monitor and oversee billing, claims, and accounts payable/receivable processes. The position also supports participant government program eligibility (MassHealth and Medicare), as well as PACE business office functions.

Responsibilities:

• Oversee the claims process from authorization to payment in coordination with the plan’s third party administrator (TPA)
• Monitor and process claims authorizations
• Review/approve/process weekly claims invoice and payment detail reports, as well as monthly invoices for private pay and spend-down plan participants
• Monitor, research, and resolve pended claims and coordinate participant claims inquiries 
• Review and approve subset of invoices prior to submission to TPA
• Answer vendor calls/questions not initially resolved by TPA 
• Coordinate vendor single case agreements with PACE clinical operations staff, vendor, TPA, etc.
• Research and resolve vendor claim appeals
• Oversee the participant coordination of benefits (COB) list and ensure accurate claims payments for COB patients, coordinating between health plans to resubmit claims as needed
• Support contracting, i.e. provider network development operations
• Manage data files such as: enrollment, MMIS, TPA reports, MMR, etc.
• Analyze, approve, and process a variety of PBM and TPA reports
• Process department’s purchase orders and billing as needed

Qualifications:

• Three to five years of experience working in health care claims/billing administration.
• Proficiency with computer systems, database applications, and spreadsheets.
• Strong interpersonal skills, both written and verbal. 

 
In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.