Financial Compliance Data Manager II

Job Summary

The Financial Compliance Data Manager II is responsible for providing assistance and support to the Claims department to collect Medicare/ Cal MediConnect  (CMC),  Organization Determination, Appeals & Grievances (ODAG) data from Participating Physician Group (PPG's) and Specialty Health Plans (SHP) . The data validation template created in visual basic will need to be maintained and updated as necessary. This position will support PPG and SHP questions about the technical data collection process. This position will also support the AB1455 data upload process and reporting required by the State. This position will assist in the collection of PPG claims audit populations for audit samples purposes. This position will also support the annual CMC/ Centers for Medicare and Medicaid Services (CMS) audit by Advent/ Medicare Data Validation Audit  (MDVA) to validate data integrity. (OMT) Online Monitoring Tool (OMT) by Gorman) will also be updated and reported to Regulatory Affairs and Compliance (RAC) for support of CMS regulatory reporting requirements. 

Duties

Oversees the updates and maintains policies and procedure for database manual, as well as provide continuous training and education to users in order to improve the processes for inputting and overall database efficiency. Trains the Medicare data analysts in the collection and follow-up with PPG's and SHP's on a regular basis. Supports PPG and SHP technical questions relating to the submission and use of the data collection template. Assists in the upload of data to Oracle as necessary. Assists in preparing reports for CMS and/or Gorman Health Group audits. Prepares custom queries and generates reports as required. 

Supports the quarterly and annual AB1455 data upload process of MTR data required to be submitted to the State. Prepares and analyzes data as required. 

Maintains CMC/ODAG data collection template. Modifies parameters to ensure  compliance with Medicare regulatory data standards. Assists in the collection of paid claims data universes for claims audit samples. Prepares data and sample selections for the PPG Claims audits. Prepares data reports and perform analysis as requested. Maintains the Medicare data validation template.  Coordinates data validation with the Claims department and Medicare Operations and assists in corrective actions plans if required.  Validates data to ensure data is accurate and complete in the approved CMS format. Supports PPG and SHP technical questions relating to the submission and use of the data collection template.

Assists in the collection of MTR/CMC paid claims data for the annual MDVA/Advent audit. Reconciles and validates data integrity. Prepare reports as requested. 

Maintains and updates Claims Audit automated work papers to ensure updated Medi-cal rate tables are uploaded and to ensure queries are running properly.

Populates Gorman OMT (Online Line Monitoring Tool) for Specialty Health Plans which is required by RAC for CMS requirements.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 6-8 years experience in a technical function utilizing multiple software applications with Healthcare HMO experience.

Skills

Required:
Requires Information Technology (I.T.) programming skills to modify parameters and to ensure compliance with Medicare regulatory data standards.

Expert knowledge in databases and report writing.

Advanced knowledge of Visual Basic, SQL, Oracle, Access, Hyperion and Crystal reports.

Strong verbal and written communication skills as well as strong interpersonal skills. 

Ability to prioritize multiple projects without compromising desired timelines.

High level of independent judgment.

Must be flexible, organized, and able to handle multiple tasks simultaneously.

Must have keen analytical skills accompanied by knowledge of the business and technology and has ability encompasses broad knowledge required from Centers for Medicare and Medicaid Services(CMS), California Department of Health Care Services (DHCS), Managed Risk Medical Insurance Board (MRMIB) and other governing body.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Must have SQL Programming