Provider Data Specialist

Job Description - Provider Data Specialist (240002I2)

Description

The Provider Data Specialist is responsible for the management of the HSCSN Network provider data. This includes the capture and processing of provider demographic information related to the HSCSN Network Providers within health plan systems (i.e., credentialing, claims, utilization management, and care management systems), management of the online and published provider directories as well as the ongoing monitoring/quality review process. The Provider Data Specialist employs an analytical approach for quality assurance, drives business requirements towards opportunities to automate, leads the audit process of provider network data, and ensures the timely upload of provider data relative to new HSCSN provider contracts as well as changes to existing provider contracts and panels.

Qualifications

Minimum Education
High School Diploma or GED (Required)
Bachelor's Degree in Business, Health Care Management, Health Care Administration, or Information Technology (Preferred)

Minimum Work Experience
3 years prior experience required working with managed care and/or health care setting.
1 year experience required in:

• Working with provider and health plan data sets required
• Knowledge of claims, network development, provider network operations, provider relationship management, and provider demographic data sets and identifiers, required
• Knowledge of Medicaid and other State and Federal mechanisms, i.e., claims processing, UM programs, provider contract administration, NCQA, HEDIS, required
• Excellent public presentation, negotiation, stakeholder facilitation, time management, problem-solving skills

1 year experience preferred in:

• General knowledge of legislative and government activities and marketplace issues affecting the region, preferred
• Experience with developing and implementing provider data quality processes, highly preferred
• Medium to high-level proficiency in Microsoft Word, Excel, Access, and Visio, required. SQL, highly desirable

Job Functions

• Manages the provider add/change process and ensures the timely update and entry of provider demographic data within core health plan systems (i.e., QNXT claims systems, Guiding Care utilization management and CM systems). Adheres to system requirements and standards as it relates to provider data completeness and accuracy.
• Ensures the appropriate and accurate entry of provider data.
• Develops tracking, reporting, and metrics for provider add/change information.
• Supports regulatory reporting related to provider add/change activity.
• Develops quality assurance process and conducts quality review. Develops plan for data corrections, where needed.
• Analyzes provider data quality across Health Plan systems. Identifies gaps and/or data misalignment and makes the appropriate updates and corrections, as needed.
• Develops and leads audit processes with the Provider Network Team and cross-functionally, as needed.
• Supports provider add/change process as it relates to roster update process received from provider delegates.
• Supports provider data strategies and initiatives as it relates to health plan system implementations and/or expanded system functionality.
• Supports and manages the provider file and process as it relates to the online and published Provider Directories.
• Works closely with the Provider Network Team and other Health Plan Teams to develop business requirements related to provider data management automation and/or reporting, as needed or required.
• Ensures proper loading of provider demographic information to support the accurate, technical implementation of HSCSN Provider contracts.
• May perform other duties in addition to those outlined in this job description.

Organizational Accountabilities

• Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved.
• Innovates through improvement of care and/or efficiency of operational processes.
• Dedicated to a standard of performance excellence and high quality.

All In

• Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency.
• Identifies, prioritizes and selects alternative solutions to determine best outcome.

Action Oriented

• Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands.
• Anticipates problems and attempts to solve before they develop.

Primary Location : District of Columbia-Washington

Work Locations : HSCSN - Vermont Ave 1101 Vermont Ave NW Washington 20005

Job : Non-Clinical Professional

Organization : HSC W/Special Needs

Position Status: R (Regular) - FT - Full-Time

Shift: Day

Work Schedule: 8:00 - 4:30pm

Job Posting : Sep 10, 2024, 7:33:48 PM

Full-Time Salary Range : 54516.8 - 90854.4

Health Services for Children with Special Needs (HSCSN) is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender identity, or other characteristics protected by law. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your Rights Pay Transparency Nondiscrimination Poster.

Please note that it is the policy of Health Services for Children with Special Needs (HSCSN) to ensure a “drug-free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances, by all staff (management, employees and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug-free workplace, including prohibiting recreational or prescribed marijuana.