Capitation Program Analyst - Exempt - Full Time - Adventist Health Ukiah Valley

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Finance
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Northern California Region
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59467 Requisition #

Adventist Health is more than an award-winning health system. We provide whole-person care to our communities and champion the greater good - from the operating room to the boardroom, we are driven by our unique passion to live God's love through health, wholeness and hope. From Oregon to Oahu, we have a calling to always do more. Now is your chance to apply your passion to our mission.

Located in a town filled with charm and rich in character, Adventist Health Ukiah Valley is an acute care hospital and 21 clinics serving communities from the Mendocino coast to Lake County. In addition to standard acute services, Adventist Health Ukiah Valley has a level IV trauma center, maternity and level II intensive care nursery services, an extensive physical rehabilitation program, outpatient surgery and diagnostic center and an advanced wound care center. Its network of clinics include primary care and specialty care, from internal medicine, gastroenterology and urology to otolaryngology.

Ukiah is situated just two hours north of San Francisco and 45 minutes from the Pacific Coast, Ukiah is also filled with terrific scenery, outdoor activities, and a beautifully restored historic downtown, where freedom of expression is a tradition and a way of life.

We're looking for someone to join our team as a Capitation Program Analyst who:

Tracks and reports organization utilization by members of the organizations capitation contracts and assists care managers in managing organization utilization of services. Maintains a database of inpatient and emergency utilization both in the organization and in out of network facilities so that care managers may intervene as appropriate and to ensure claims expense against the risk pool are accurate.

Essential Functions:

 

  • Reviews patients daily with Case Management and identify patients requiring Case Management intervention. Ensures authorization for services and track stay according to authorization. Notifies case management of issues.
  • Monitors reinsurance claims expense and payments. Monitors daily inpatient and emergency stays. Obtains copies of clinical information from Out of Area (OOA) hospitals. Identifies California Children Services (CCS) eligible conditions and makes California Children Services (CCS) referrals according to California Children Services (CCS) criteria.
  • Checks for other insurance coverage to ensure patient should be eligible for capitation. Works with health plan to resolve issues. Closes treatment authorization requests (TARS) with approved or denied days. Meets primary health care (PHC) targets for percentage of eTARs submitted within one business day.
  • Submits required data to health plan group, primary care physician (PCP) and other key stakeholders and develops an excellent working relationship with them.
  • Participates in educational training to develop awareness of new techniques, procedures and instruments by participating in continuing education to comply with federal and state laws and to enhance professional growth.
  • Performs other job-related duties as assigned.

 

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You'll be successful with the following qualifications:

Education:

  • Associate's / Technical Degree or equivalent combination of education/related experience: Required
  • Bachelor's Degree: Preferred

Work Experience:

  • Three years relevant experience: Preferred
  • Two years experience in managed care industry or acute care patient financial services: Preferred

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA and HI) or the option of COVID-19 vaccine or weekly testing (required in OR), etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.

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