Provider Data Services Program Manager II

L.A. Care Health Plan•Los Angeles, CA

About The Position

The Provider Data Services Program Manager II leads organizes and coordinates support for Cactus data remediation in various projects, including data remediation efforts through the Symphony Utility, Data Standardized Provider Format (SPF) submissions, Data Governance Clean-Up, and Customer Relationship Management (CRM) special projects. The Program Manager II represents Provider Data Services Department and leads streamlining auditing areas of compliance. This position supports the Director of Credentialing and Data Management through oversight of all data remediation in Cactus. This position primary duties shall include collaboration with the Appeals and Grievances Department and leading the re-development of a compliant process that monitors provider complaints in L.A. Care's network. This position is the business lead for provider data reports required for Credentialing compliance with regulatory audits. The Provider Data Services Program Manager II also leads Cactus provider data remediation efforts through Symphony, Data Governance, and Standardized Provider Format (SPF) submissions. Additionally, this role manages Cactus Imports and Exports modules, manages implementation of upgrades to Cactus modules, and manages inputs or outputs in the Cactus environment that supports Information Technology (I.T.) and Product. This position acts as the Business Lead for Credentialing data reporting, resolves complex problems, and works with moderate guidance and direction from the Senior Director. This individual also initiates and develops strong interpersonal relationships with both internal L.A. Care staff and external business partners in order to facilitate joint decision-making and successful program implementation to support delivery of timely and accurate data remediation through Cactus.

Requirements

Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered.
At least 5 years of credentialing auditing experience in a managed care or hospital setting.
Proven experience conducting root-cause analyses, policy requirements, and managing highly visible organizational programs.
Experience building relationships with organizations and business partners.
Strong knowledge of NCQA Credentialing Standards, CMS and DHCS regulatory requirements.
Strong knowledge of Symplr Cactus database systems.
Knowledge of metric management methodology.
Demonstrated critical thinking, problem solving, and program planning and implementation skills.
Demonstrated strong writing and communication skills.
Demonstrated ability to synthesize and analyze qualitative and/or quantitative data.
Proven knowledge of data entry and reporting management within Symplr Cactus database.

Nice To Haves

Master's Degree
Experience working with managing programs or other managerial experience.
Managed care experience.
Certified Provider Credentialing Specialist (CPCS)
Project Management Professional (PMP)

Responsibilities

Formulate and propose recommended solutions/ options to address moderately complex operational and programmatic challenges with Cactus provider data remediation, with moderate guidance from Senior Director.
Assume ownership of data remediation initiatives for Cactus, under direction of Senior Director, for successful development, planning, and execution of programs, data reporting, analysis and improvements to infrastructure, from initial concept to implementation stage, with moderate guidance and supervision from Senior Director.
Represent Cactus database interests and initiate engagement of existing internal and external business partners colleagues, to jointly problem-solve complex member and provider issues. Facilitate constructive dialogue among internal and external stakeholders to ensure problems are properly assessed, analyzed and resolved, with moderate guidance and supervision from Senior Director.
In concert with other departments, work to draft work plans, policies and procedures that define business needs for Cactus data remediation, including , scope, key milestones and tasks necessary to guide the implementation of new program initiatives, such as Target State, Data Governance, and development of an Appeals & Grievances process for the Direct Network. Maintain work plan updates to capture any changes that arise throughout from each initiative, ensuring Cactus alignment with downstream business processes across the organization.
Manage progress and performance as it relates to Cactus tasks; track and report on program status. Identify issues that must be escalated in order to ensure timely completion of program. Manage internal and external meetings, including the development of agendas and objectives. Propose solutions to address and mitigate any anticipated program delays and steer program in positive direction. Execute workflow processes developed by Provider Data Services (PDS) Director for Appeals and Grievances processes; ensure oversight monitoring process in place. Lead oversight and monitoring of Credentialing provider data reports for regulatory audits.
Serve as L.A. Care business program lead in external stakeholder meetings on behalf of the Provider Data Management team, as required. Serve as L.A. Care business program lead and actively participate in L.A. Care committee standing meetings and management meetings on behalf of the Provider Data Services team, as required with moderate guidance and supervision from Senior Director.
Perform other duties as assigned.