Provider Finance Financial Analyst III

Job Summary

The Provider Finance Financial Analyst is responsible for processing activities for all system SAP and QNXT applications and the Capitation and Shared Risk  financial activity for all lines of business and Full, Dual and Shared Risk contractual agreement with Participating Provider Groups (PPGs), hospitals and ancillaries. This position will prepare and review all regulatory reporting, month end files and reports. 

The position will process accurate membership reconciliations, configuration of contracted rates, and provider information in SAP for full, dual and shared risk contracts, with participating physician groups (PPGs), hospitals and  ancillary providers for lines of business Medi-Cal(MCLA), Medicare(DSNP) LACC, LACCD, PASC, PASC/COBRA and CAL AIM.  This will include provider incentives, claims analysis, (DFOR) Division of Responsibility, journal entry posting,  account and variance analysis, month-end reconciliations and preparation of financial reporting tools for contracted  Participating Provider Groups (PPGs), hospitals and ancillary for capitated and/or shared risk  lines of business.  Provides recommendation on the capitation/shared risk contractual agreement language.

This position will interface and communicate with cross functional teams, SAP, Member Services, Configuration, IT, Provider Network Operations and external providers and auditors on capitation and shared risk processing.  They will participate in process improvement testing and development requirements. They will become familiar with all (DHCS) Department of HealthCare Services and (CMS) Center for Med-Cal and Medicare Services  regulatory requirements reporting .

This position will communicate and elevate  to supervisor and manager abnormalities, root cause and resolutions, work with SAP to maximize efficiencies for continue process improvement  and automation.  

Acts as a  Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Capitation: Reconciles the monthly membership interfaced from QNXT to SAP into a centralized processing SAP system, reconciles and maintain SAP system  membership for all full, dual, shared risk and ancillary contracts, with participating physician groups (PPGs), hospitals and  ancillary providers for lines of business Medi-Cal(MCLA), Medicare(DSNP) LACC, LACCD, PASC and CAL AIM, capitation calculation including configuration in SAP of new rates (Per member per month (PMPM) and Percent of Premium, retroactive rate changes, retro active enrollment and disenrollment and the processing to incorporate the actual Gross capitation figures into  SAP from QNXT systems on a continuous basis. Reviews eligibility lists (E-List) and accurate net capitation, post all cap deducts, calculations are accurate and  posted to provider portals according to contractual agreements. Collaborates with QNXT configuration and provider contracting to manages the QNXT updating of contracted provider capitation information. Communicates and elevates abnormalities, root cause and recommendations. Meets processing within specified time limits outlined in regulatory SB260 guidelines and capitated service agreements for the providers. Responds to disputes in a timely manner. 

Shared Risk: Exports membership from SAP systems to effectively calculate budgeted revenue and add all supplemental capitation to Shared Risk pools, configures in SAP line of business with shared risk contractual agreements to ensure DFOR is in accordance to contracted (HCPCS) Healthcare Common Procedure Coding System codes, acceptable claim form bill types, perform claims analysis, reconciles and maintains cost of care expense codes to ensure SAP and QNXT are reconciled and the SAP financial system is reporting accurately into LA Care financial statements, maintain SAP tables to configure rates, Per member per month (PMPM) and Percent of Premium, including retroactive rate adjustments, realignment of member expense with Revenue to ensure movement to be in sync with PPG transfers and generate the monthly, quarterly shared risk statements and annual settlements are accurate and post to provider portals according to contractual agreements and the processing are made within specified time limits outlined in regulatory SB260 guidelines. Respond to disputes in a timely manner.
 

Duties Continued

Provider Incentives: Accurately reconciles provider enrollment and expense, and report monthly Cal Aim provider Incentives.  These payments must be reconciled to encounter submissions and the recovery plan must be followed for overpayments in accordance with each unique provider contractual agreement. Collaborates with various departments to ensure necessary communication and data received for reporting the ongoing balance reconciliation. Elevates and communicates contractual or balance forward inconsistencies  

Accurate preparation of the journal entries and  general accounting reconciliations  internal and external audits, and PPGs, hospital and ancillary requests. Develops, describes, analyzes, and validates datasets; verifies and corrects data, models, and reports; implements, upgrades, and develops data management and visualization tools; and creates reporting tools/ models to explain and forecast data.

Participates with Provider Finance management to collaborate with Information Technology, SAP and external vendors on the design, development and implementation of tested process improvement for an effective data analysis and reporting  to maximize SAP efficiencies to assist and ensure the department in time saving automation implemented by SAP.  Contributes on the preparation of the development requirements. 

As subject matter experts (SMEs), creates and maintains desk top procedures and processing guidelines for the analysis and management of data. Reviews the functions to ensure regulatory compliance pertaining to capitation expenses and shared risk, including  fraud  and abuse verification.

Perform other ad-hoc duties as assigned and participate on new projects as deemed necessary. 

Education Required

Education Preferred

Experience

Required:
At least 3-5 years of experience in a healthcare setting (HMO and IPA) and Capitation/Shared Risk. Experience in calculation of Provider's Capitation and Shared Risk, provider service agreements and DOFR interpretation.

Preferred:  
Experience with Medicare / Medi-Cal, SAP/QNXT systems experience a plus.

Skills

Required:
Extensive knowledge of accounting, capitation and Shared Risk. enrollment and retroactivity processing 

Ability to work with complex databases, excellent data management and problem-solving skills.

Proficiency in Advanced Microsoft Excel, Word, Microsoft SQL  and Monarch

Familiar with claims, i.e. (HCPCS) Healthcare Common Procedure Coding System codes, Current Procedural Terminology (CPT) codes, place of service and billing practices. 

Ability to work in a team environment.

Ability to read, analyze and interpret State bills, technical procedures, governmental regulatory requirements and contractual agreements. .

Excellent communication skills, oral and written.

Preferred:
Medi-Cal, Medicare knowledge.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information