Senior Data Validation Program Manager

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Senior Data Validation Program Manager reports to the Director of Dual Special Needs Plan and is responsible for implementation and monitoring of the Medicare Data Validation requirements for Part C & D and SNP, as well as Medi-Cal Data Validation. This position will support and ensure that impacted businesses departments are tracking and adhering to the technical and reporting requirements.  This includes but not limited to the following:  Model of Care, Network, Utilization Management, Pharmacy Part D, and Grievance and Appeals, and Risk Adjustment for both C and D Data Validation. 

The successful candidate is a subject matter expert (SME) in regulations that govern the CMS Medicare D-SNP and Medi-Cal reporting requirements and in the application of operational strategies and tactics to maximize the annual Data Validation audit scores. The Senior Data Validation Program Manager will serve as a high-level individual contributor. 

Amount of Travel Required: 10-20%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

Reporting and Documentation:

•    Leads in generating detailed reports on data validation findings, documenting validation procedures, and maintaining comprehensive documentation for audit purposes.

Issue Resolution:

•    Leads issue resolution organizationally by investigating data quality issues, collaborating with relevant stakeholders to resolve discrepancies, and implementing corrective actions to prevent future errors. 

Data Quality Analysis:

•    Leads data quality analysis in conducting thorough data quality reviews, identifying data inconsistencies, anomalies, and potential errors across various data sources.

Developing Validation Strategy:

•    Designs and implements comprehensive data validation plans, defining data quality metrics, and establishing standards for data acceptance criteria. 

Compliance Assurance:

•    Ensures adherence to data quality standards, regulatory requirements, and industry best practices.

Process Improvement:

•    Identifies opportunities to optimize data validation processes, implementing new tools or technologies to enhance efficiency and effectiveness. 

•    Participates in the development of new processes and best practices and assist with providing training and awareness to other business groups affected by new activities. 

Stakeholder Management:

•    Communicates validation results to key stakeholders, including business owners, data analysts, and project managers, and addressing any concerns raised. 

MINIMUM QUALIFICATIONS

Education & Experience: 

Required Education and Experience:

•    Bachelor’s degree in health or business related such as Public Health, Health Administration, or Social Work

•    5 years of analytics experience required 

•    Working knowledge of NCQA standards, SNP requirements, DHCS and CMS regulations

•    Five or more years of experience providing complex analytical and/or project implementation support, including but not limited to regulatory review and analysis

•    5 years of experience in data universe preparation and validation 

Preferred Education and Experience: 

•    Master’s degree in health or business related such as Public Health, Health Administration, or Social Work

•    5 yrs of experience working in a highly matrixed, mission-driven organization

•    Comfortable with presenting in front of leadership 

•    Experience with healthcare data including but not limited to care management, claims, authorizations, grievances, appeals, and call center 

•    Advanced experience with Microsoft Excel

Equivalent In lieu of degree:   

•    Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position.

•    Four years of experience must be added in lieu of a bachelor’s degree.

KNOWLEDGE, SKILLS & ABILITIES    

Preferred Qualifications:    

•    Ability to maintain a calm demeanor at all times, including during highly charged situations.

•    Ability to establish, nurture and maintain strong and effective working relationships with GCHP staff, governmental and regulatory staff, legal counsel, and others. 

•    Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.

•    Ability to assume responsibility and exercise good judgment with making decisions within the scope of the position. 

Technology & Software Skills: Advanced computer skills in MS Office products and familiarity with PowerBI.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements

•    Business Acumen - Ability to grasp and understand business concepts and issues.

•    Decision Making - Ability to make critical decisions while following company procedures.

•    Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

•    Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

•    Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

•    Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

•    Judgment - The ability to formulate a sound decision using the available information.

•    Communication, Written - Ability to communicate in writing clearly and concisely.  

•    Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.