Quality Analyst II

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 285,000 members in California, Arizona, Nevada, and Texas. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn; Facebook; and Twitter.

The Job

Ensure that the activities of the Enrollment, Reconciliation, and Premium Billing Department adhere to guidelines established by the Centers of Medicare and Medicaid Services (CMS), the Department of Health Care Services (DHCS), and other regulating agencies.

Support business units external, and internal, to the Enrollment, Reconciliation and Premium Billing Department with production, reconciliation, and auditing efforts by completing regular and ad hoc projects involving data validation and reconciliation.

Support the Enrollment, Reconciliation and Premium Billing Department's maintenance and development efforts for critical core systems used to store membership eligibility data, membership eligibility history, retired systems data, and file/record management.

You Will

• Execute daily systematic validations against the core processing systems to ensure departmental completion of critical processes performed to maintain eligibility details for the organization's membership.
• Review applicable organizational communications regarding changes to regulatory requirements and/or changes in data report file layouts and specifications from any/all regulatory agencies. Provide impact analysis for all related processes currently in place within the department and draft action plans to address and incorporate changes into the routine operations of the department.
• Participate in, and/or lead process design sessions to develop new processes, enhance, or remediate existing processes in response to changes in regulatory requirements or data file specifications.
• Support, or lead, regulatory audits of eligibility data and/or processes governed by the Enrollment, Reconciliation and Premium Billing Department by reviewing and interpreting audit requests and requirements, presenting final analysis and proposed strategies to management on how to fulfill audit requests, researching and documenting findings for audit selections during the external agency audit procedures, and pulling and providing individual documents for selected cases during the external agency audit procedures.
• Conduct routine process analysis for department's operating procedures and validate compliance with regulatory requirements or develop details assessment outlining gaps/risks identified with proposed process redesigns to mitigate identified gaps and risks.
• Develop and implement operating procedures to support the department's production and reconciliation processes by developing a series of queries to interpret and develop data results and developing standard operating procedure documents to outline the operating actions to be performed.
• Develop and perform routine audits internal to the Enrollment, Reconciliation and Premium Billing Department by identifying measurable regulatory requirements applicable to departmental processes, developing methods designed to accurately measure the department's compliance with the requirement, identifying the applicable audit universe within the review period(s), creating sample selections, reviewing individual cases and results to identify outliers, and reviewing results with management with proposed solutions to remedy findings.
• Develop and maintain departmental Policy and Procedure documents used by the organization to evidence the plan's standard operating procedures that support critical business functions and demonstrate compliance with regulatory requirements.
• Work directly with external system and fulfillment vendors to maintain system functionality and accuracy, configure annual enhancements or changes, and resolve identified deficiencies.
• Develop and execute strategic testing plans for all system implementations or enhancements by drafting and executing test plans with internal business units and by leading and coordinating, testing efforts with externally assigned teams. Participate in creating process workflows and functional design documents to outline business requirements for projects related to enhancing current systems or processes and to implement new systems or processes.
• All other duties as assigned.

Your Qualifications

• 2-3 years of Eligibility & Reconciliation experience, preferably within a health plan or healthcare company.
• Experience working with IKA platform
• 2+ years' experience with health services industry and managed care business.
• Proficient with MS Office (Access or SQL, Word, Excel, PowerPoint) and e-mail.
• Ability to work independently and in a team environment.
• Ability to work under tight deadlines & manage multiple responsibilities independently.

What's in it for you?

• Base Pay Range: $52,800 - $84,500 (Annually)
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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