Provider Network Data Integrity Analyst - Health Plan
About The Position
This position is responsible for the accuracy, completeness, and required regulatory filings of the Health Plan’s (HP) provider network. Serves as a resource for strategic planning, compliance, and network analysis. Responsible for completion of network adequacy filings for Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), Department of Health Services (DHS), and requested employer groups. Accountable for the maintenance, enhancements, and overall data integrity to ensure the Health Plan’s provider directory meets established CMS standards. Develops and enforces data quality standards within the provider and facility database to ensure that credentialing software is a source for up to date accurate record information. Completes network adequacy reviews, in collaboration with the Health Plan's Business Intelligence Department representatives to include Center for Medicare and Medicaid Services (CMS) time and distance standards, ensuring HP meets required network standards to expand their service area. Performs analyses and audits to identify gaps in current provider networks to ensure corrections are made by contracting to maintain compliance with required adequacy standards. Coordinates required regulatory provider network submissions to ensure HP meets contractual obligations. Audits and advises provider credentialing on identified data issues, including working with delegated credentialed entities, to ensure that complete and accurate information is being received. Maintains accurate data in HP Provider Directory to ensure it's in compliance with CMS, Department of Health Services (DHS), and Office of the Commissioner of Insurance requirements. Organizes a large amount of data into easy to understand formats to help aid in strategic planning for HP. Maintains a strong understanding of providers and facilities in current HP's service area and patterns of care to help identify opportunities for potential expansion. Researches and communicate regulatory directives to ensure HP maintains compliant practices. Performs disruption analysis for potential customers of HP to identify potential improvements to effectively provide competitiveness for bids. Other duties as assigned.
Requirements
- Bachelor’s Degree in business administration, finance, healthcare related field, computer science, or analytics.
- Three years’ experience in a medical group practice, health insurance or Health Maintenance Organization (HMO) environment.
- Demonstrated knowledge of data manipulation and analytical analysis.
- Proficiency with Microsoft Office suite to include products, Excel and Access.
Nice To Haves
- Successful completion of a post-secondary medical terminology course preferred.
- Understanding of geoaccess coding, provider credentialing, and medical terminology preferred.
Responsibilities
- Develops and enforces data quality standards within the provider and facility database to ensure that credentialing software is a source for up to date accurate record information.
- Completes network adequacy reviews, in collaboration with the Health Plan's Business Intelligence Department representatives to include Center for Medicare and Medicaid Services (CMS) time and distance standards, ensuring HP meets required network standards to expand their service area.
- Performs analyses and audits to identify gaps in current provider networks to ensure corrections are made by contracting to maintain compliance with required adequacy standards.
- Coordinates required regulatory provider network submissions to ensure HP meets contractual obligations.
- Audits and advises provider credentialing on identified data issues, including working with delegated credentialed entities, to ensure that complete and accurate information is being received.
- Maintains accurate data in HP Provider Directory to ensure it's in compliance with CMS, Department of Health Services (DHS), and Office of the Commissioner of Insurance requirements.
- Organizes a large amount of data into easy to understand formats to help aid in strategic planning for HP.
- Maintains a strong understanding of providers and facilities in current HP's service area and patterns of care to help identify opportunities for potential expansion.
- Researches and communicate regulatory directives to ensure HP maintains compliant practices.
- Performs disruption analysis for potential customers of HP to identify potential improvements to effectively provide competitiveness for bids.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
