Health Plan Specialist
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May 1

Health Plan Specialist

Brandman Centers for Senior Care (BCSC)
Full Time
8:30am - 5:00pm
Reseda, CA

We value our employees! We offer long term employment opportunities with job stability, including supporting and encouraging career growth advancement. We offer Health, Dental and Vision insurance, Paid Time Off, 9 Paid Holidays, 403(b) with Matching Retirement Plan, Life insurance (paid by the company) and a team spirit workplace culture!

Candidates should be aware that Los Angeles Jewish Health (LAJH) currently maintains a policy requiring employees to be fully vaccinated. New LAJH employees should be fully vaccinated (i.e., two weeks after last dose) by their start date. LAJH is an equal opportunity employer, and will provide reasonable accommodation to those unable to be vaccinated where it is not an undue hardship to the company to do so as provided under federal, state, and local law.

Administrative Functions

  1. Serve as a point person to assist vendor with the completion of health plan management set up and maintenance by providing:
    1. Copies of participant’s demographic and entitlement information.
    2. Copies of provider contracts and current Medicare Part D bid.
    3. Accounts payable and accounts receivable beginning balances and detail.
    4. Chart of accounts.
    5. Current IBNR detail including any outstanding inpatient claims.
  2. Maintain access to health plan management vendor system to generate reports and review data status.
  3. Ensure all administrative invoices into Oracle, research and respond to phone call, email and fax inquiries regarding invoice receipt and payment
  4. Submit enrollment and disenrollment information to health plan management vendor and DHCS, as requested.
  5. Verify proper Centers for Medicare and Medicaid (CMS) capitation rates via CMS’ rate book.
  6. Review Monthly Membership Report (MMR) generated by health plan management vendor in excel format.
  7. Provide claims to health plan management vendor for processing.
  8. Prepare manual checks for Executive Director’s signature.
  9. Communicate with health plan management vendor to assure accurate payment and provide updated provider contract as needed.
  10. Review weekly report of authorized and unauthorized claims.
  11. Clear SOC monthly with DHCS.
  12. Record 820 DHCS payment detail on payment spreadsheet monthly.
  13. Collaborate with health plan management vendor to determine each permanently-place SNF participant’s share of cost and make proper deductions from monthly nursing home bills.
  14. Review monthly general entry generated by health plan vendor per the financial close calendar.
  15. Enter service authorizations and/or support electronic service authorization imports to health plan management vendor based on file specifications.
  16. Review monthly IBNR and accounts payable aging reports.
  17. Provide in-center encounters to health plan vendor for quarterly risk adjustment data submission to CMS.
  18. Review immediate correction of errors in risk adjustment data.
  19. Review semi-annual Risk Adjustment Data reports provided by health plan management vendor to identify variances.
  20. Support relevant regulatory reporting.
  21. Participate in monthly client teleconferences with health plan management vendor and key LAJH staff.
  22. Stay current on CMS’ data reporting requirements via the Health Plan Management System (HPMS), NPA conference calls and CMS communication.
  23. Research and take necessary action to resolve Medi-Cal eligibility issues.
  24. Review Capstone audits and schedule meetings with providers.
  25. Research and resolve errors on RAPS return files.
  26. Research statements received by participant to make sure providers have the correct insurance information in order to process claims for payment.
  27. Understands fiscal issues and is appropriately involved in meeting budget targets.
  28. Consistently meets or exceeds BCSC target for productivity.
  29. Continually seeks better ways for delivering services and communication.
  30. Consistently meets or exceeds BCSC customer services targets.
  31. Demonstrates respect for and promotes participant right including dignity, self-determination, access to care, confidentiality and independence.
  32. Effectively collaborates with staff peers and contractors to meet BCSC goals and further success.
  33. Complies with all policy and procedures of BCSC.
  34. And other duties as assigned.

Education and Experience

  • Degrees and diplomas: High school diploma required. Bachelor’s degree preferred.
  • Certificates, licenses: Must have a valid California driver’s license. TB screening and successful completion of a health examination by a health care provider is required for employment.
  • Experience: Qualified professional in the field of health plan claims management with demonstrated or potential competence in working with health plan management functions. Five years of experience with at least 2 years supervisory experience. Knowledgeable about senior health care and PACE.
  • Skills/Aptitudes: Ability to provide care for the frail elderly. Ability to work independently and to lead a interdisciplinary Team. Good organizational and supervisory skills. Ability to handle complex interpersonal situations


Health Plan Specialist

Please upload your resume or fill out the application.
Highest level of education completed.