Analyst, Provider Quality
About The Position
The Analyst, Provider Quality assists the Manager, Provider Quality in executing and maintaining provider and prescriber data quality that directly impact pharmacy claims accuracy, regulatory compliance, and operational performance. This role monitors prescriber data for accuracy and integrity, investigates and resolves data quality issues, and ensures adherence to established governance controls and regulatory requirements. The Analyst, Provider Quality works cross-functionally with Compliance, SIU, IT, and business stakeholders to support audit readiness, manage data-related risks, and improve data accuracy across internal systems and external data sources. The Analyst, Provider Quality also contributes to process improvements, reporting, and automation efforts to enhance data governance, operational efficiency, and overall quality outcomes.
Requirements
- Bachelor’s degree or equivalent work experience required.
- 2 years of experience working with provider data and/or validation through healthcare billing, accounts receivable, or credentialing required.
- Experience with data analysis, healthcare claims processing, issue resolution, and process improvement required.
- Participate in, adhere to, and support compliance program objectives.
- The ability to consistently interact cooperatively and respectfully with other employees.
Responsibilities
- Monitor, validate, and maintain provider and prescriber data to ensure accuracy, completeness, and compliance with regulatory and organizational requirements.
- Ensure proper intake, triage, and prioritization of data quality issues, ensuring timely resolution based on risk, impact, and business needs.
- Investigate and resolve data discrepancies or duplications impacting claims adjudication, system performance, and reporting integrity.
- Assist with the resolution of Prescriber Edits on claims.
- Perform root cause analysis to identify recurring issues and recommend corrective actions to improve data quality and prevent reoccurrence.
- Support validation and reconciliation of internal and external data sources, including vendor-provided data feeds and enrichment files.
- Outreach to prescriber data authorities, including CMS and State Medicaid Programs, to resolve data clarity issues.
- Assist with and resolve issues related to sanction monitoring, defects, state or federal exclusion conflicts or other provider restrictions that may impact claims.
- Escalate complex challenges, overrides, or data conflicts timely and inclusive of actions already taken.
- Prepare and validate documentation to support audit readiness, regulatory inquiries, and client requests, ensuring accuracy and completeness.
- Execute established data governance controls, including data validation checks, exception handling, and adherence to defined processes.
- Maintain and update standard operating procedures (SOPs), work instructions, and supporting documentation related to provider data quality processes.
- Track, analyze, and communicate data quality trends, risks, and performance metrics to inform decision-making and process improvement.
- Other duties as assigned.
Benefits
- Health, Dental, and Vision insurance
- 20 days paid time off
- 4 weeks paid parental leave
- 9 paid holidays
- 401K company match of up to 5%
- Adoption Assistance Program
- Flexible Spending Account
- Educational Assistance Plan and Professional Membership assistance
- Referral Bonus Program – up to $750!
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
