Finance and Health Plan Operations Administrator- PACE

TriHealth is actively recruiting for a Finance and Health Plan Operations Administrator to work with the PACE of Cincinnati PACE Center located in Norwood Ohio. Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.

Job Overview:

This role presents an extraordinary opportunity for a mission-driven leader to play an integral role in establishing and managing the finance and health plan operations of a dynamic, integrated care delivery startup. This role will be responsible for building, scaling, and continuously improving PACE Health Plan Operations functions efficiently and effectively, which includes, but is not limited to, TPA management/oversight (claims), utilization management, and provider network administration. Develops and manages annual operating and capital budgets.

Job Requirements:

Master's Degree Relevant field including business, MBA, accounting/CPA, Finance/MS, economics, math or healthcare administration/MHA (Preferred)
7 - 10 years Related experience in a comparable health care financial role (Preferred)
Passion and mission orientation for serving high-risk seniors and frail older adults 
Thrives in a relatively undefined, "zero to one" environment - unafraid to "roll up your sleeves" and drive a wide-ranging set of projects, processes, and deliverables 
Meticulous attention to detail- can build a financial model from scratch, as well as audit and adapt existing financial models 
Self-directed- takes the initiative to run down problems with relatively little direction, knows when and how to escalate effectively 
Expert proficiency in both MS Excel and PowerPoint required

Job Responsibilities:

Develop and manage annual operating and capital budgets to achieve targets. Proactive with planning, financial forecasts, and resolution of budget variance; Serve as the accountable leader for PACE Health Plan Operations functions; Manage and provide oversight to the Third Party Administrator (TPA), the Pharmacy Benefit Manager (PBM), and other key vendors, including vendor management, and receivables/payables; 
Lead provider network administration, including strategic support for negotiations, managing our catalog of contracts, properly loading all contracts into required systems/vendors, and managing the provider manual; Lead all Medicare Part D operations, including managing PBM and pharmacy services vendors; Oversee enrollment operations for Medicaid and Medicare, Medicare self-pay, and Medicaid liability and spend-down tracking 
Manage enrollment data and data systems including data transfers and the development and management of systems to meet PACE programmatic requirements; Develop and maintain effective monitoring programs for claims processing, enrollment reconciliation, Medicare Part D, RAPS, and Encounter Data submissions; Lead utilization management operations by supporting the PACE leadership teams on the ground with appropriate tools and processes that ensure efficient and timely decisions 
Lead government relations with respect to health plan operations and lead regulatory audits (e.g., PACE 1/3rd financial audit, Part D audits, enrollment data verification, and other health plan related audits); Design and support reporting required by regulatory bodies (CMS, state) and any key vendors as needed; Oversee risk adjustment compliance and documentation integrity oversight, including but not limited to coordinating the HOS survey; 
Design and support reporting needed by the operations teams (e.g., Quality, Risk Adjustment, Utilization); Manage and provide oversight to selected other external vendors related to any of the functions listed above and more, ensuring quality and adherence to protocols; Develop and maintain Health Plan Operations-related policies and procedures that meet applicable state and federal requirements 
Stay current on regulations and policies impacting the PACE program, health plan operations, and our compliance program and share that knowledge across the organization; Assist the PACE program in ad hoc special projects, collaborations with external partners, vendor contracting, and other operating model decisions; Continuously seek improvements to processes and systems across functions as the size and complexity of PACE grows;

Working Conditions:

Bending - Rarely 
Climbing - Rarely 
Concentrating - Consistently 
Continuous Learning - Consistently 
Hearing: Conversation - Frequently 
Hearing: Other Sounds - Frequently 
Interpersonal Communication - Consistently 
Kneeling - Rarely 
Lifting Lifting 50+ Lbs. - Rarely 
Lifting Pulling - Occasionally 
Pushing - Occasionally 
Reaching - Occasionally 
Reading - Frequently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Rarely 
Talking - Frequently 
Thinking/Reasoning - Consistently 
Use of Hands - Frequently 
Color Vision - Frequently 
Visual Acuity: Far - Frequently 
Visual Acuity: Near - Frequently 
Walking - Frequently

Leadership Performance Standards

TriHealth leaders create a culture of engagement, safety & reliability and high performance by consistently modeling and utilizing the following TriHealth Way leadership competencies, tactics and ALWAYS Behaviors to drive strategic pillar results:

Achievement of Annual Pillar Goals: 
1) Safety/Quality, 2) Service, 3) Growth, 4) Culture/People, 5) Finance

Leadership Competencies: 
TriHealth Way of Leading 
TriHealth Way of Serving 
Transformation Change 
Drive for Results 
Build Organizational Talent

Leadership Tactics: 
Conduct department huddles. Generally, clinical departments hold daily huddles, non-clinical hold weekly huddles. 
Regularly Round on Team Members, using questions from the rounding log. 
- 25 or fewer team members = monthly 
- 26-50 team members = every other month 
- 51+ (and optional team members) = quarterly

Lead monthly team meetings using meeting agenda template; review stoplight report; cascade key leadership messages.

Model, coach and validate team members use of TriHealth Way behaviors (AIDET + Promise, Always Behaviors and Always HEARD).

Recognize team members for safety wins, positive performance and demonstrating SERVE and ALWAYS behaviors, TriHealth Way of Leading, Serving and Delivering Care.