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Sharp HealthCare · 6 hours ago

Credentialing Data Analyst - SHP Health Services - Telecommuter - Day Shift - Full Time

United States

Full-time

Remote

Mid, Senior Level

$32.73/hr - $45.81/hr

5+ years exp

Sharp HealthCare is a leading healthcare provider seeking a Credentialing Data Analyst. This role involves coordinating credentialing functions, maintaining provider databases, and ensuring compliance with regulatory standards for the Sharp Health Plan.

Health CareNon Profit

Responsibilities

Credentialing delegation oversight

Knowledge of Department of Managed Care (DMHC), Knox Keene Act for regulations governing Health Maintenance Organizations (HMOs) and Department of Health Services (DHS) regulations regarding delegated services

Maintains current knowledge of delegation, contractual agreement(s), and reimbursement models

Maintains current knowledge of National Committee for Quality Assurance (NCQA), Department of Managed Health Care (DMHC), Industry Collaboration Effort (ICE), and Centers for Medicare and Medicaid Services (CMS) regulatory standards to ensure Sharp Health Plan credentialing processes meet all health plan contractual compliance requirements

Provides reporting, feedback and documentation, as necessary, to maintain compliance with delegated credentialing requirements

Works closely with the Credentialing Verification Organization (CVO) to manage deliverables as defined in the Sharp Health Plan / CVO delegation agreement

Responsible for review and ongoing monitoring of credentialing materials to ensure accurate and timely credentialing and re-credentialing of SHP providers within required regulatory timeframes

Responsible for plan medical group, group practice, and service ancillary credentialing delegation oversight activities through review of documents and preparation of reports applicable to the oversight process, and coordination with the CVO

Responsible for Health Delivery Organizations (HDO) facility credentialing delegation oversight to ensure adherence to NCQA and CMS standards

Conducts recredentialing review to include quality indicators such as member appeals, grievances and potential quality issues, working in collaboration with internal teams

Performs credentialing audits of delegated entities that perform credentialing functions according to their Sharp Health Plan delegation agreements to ensure compliance with Sharp Health Plan, NCQA, DMHC, CMS and other federal and state credentialing standards

Monitors compliance with corrective action plans

Works with accountable leaders to assure all action items are complete within required deadlines

Collaborates with the Medical Management and Network Management to obtain complete results of provider site audits

Prepares Peer Review Committee information summaries and presents relevant material at quarterly Peer Review Committee meetings

Prepares credentialing summaries for all practitioners meeting the Sharp Health Plan threshold criteria for "clean file" and “unclean file” review for presentation at monthly Peer Review Committee meetings

Responsible for maintaining timely, complete, accurate credentialing documentation in electronic format

Prepares accreditation information for submission and coordinates surveys for organization

Provides consultation on the development of guidelines, policies, procedures and protocols

Establishes and maintains processes to conduct annual review of delegate credentialing policies and procedures

Reviews for completeness and accuracy as it relates to regulatory standards

Develops and maintains policies and procedures for all credentialing and peer review processes in accordance with Sharp Health Plan, NCQA, DMHC, CMS, and other federal and state requirements

Participates in ICE workgroups related to credentialing activities to maintain policies and procedures in compliance with regulatory agencies

Attends internal and external meetings as appropriate

Customer service

Establishes good working relationships with providers, CVO contacts, medical directors, and all levels of internal and external customers

Demonstrates ability to be flexible and prioritize to meet the needs of the organization

Prepares clearly written and professional work products

Demonstrates cooperation and teamwork and assists others as needed

Accepts interpersonal differences and promotes cooperation with colleagues

Fosters open lines of communication and informs leadership of any issues relating to compliance or organizational risk

Coordinates and completes assigned projects as required

Performs other duties as assigned by the Network Management and Application Optimization, Manager

Database management

Familiarity with basic principles of relational database management and elements of a database

Builds database queries and sets up job scheduling

Ensures the maintenance of the provider database and is responsible for reporting accurate information for required reports and provider directories

Experience developing and identifying processes by which reports are compiled using relational databases

Responsible for maintaining data integrity by systematically auditing database entries

Develops and maintains timely database policies and procedures

Identifies and takes action on IT upgrades to achieve database efficiencies, ease the burden of manual processes and implement department process improvements to maximize efficiency, effectiveness, and productivity in daily work activities

Analyzes database administration inefficiencies and streamlines processes accordingly

Statistical Reporting

Produces and reviews statistical reports to monitor delegation oversight and network activities

Prepares complex charts and graphs to summarize and visualize report data on an as-needed basis

Responsible for validating the accuracy of statistical reporting, e.g., regulatory filings, dashboards, et al, based on database queries and abstracts

Tracks and trends identified reports to monitor network activity

Ensures accuracy of provider data extracts used for provider directories through data validation procedures

Ensures accuracy of management and regulatory reports

Compiles statistical reports, on a frequent basis, to demonstrate productivity and efficient workflow processes

Process improvement

Utilizes a continuous quality improvement approach to identify and initiate department process improvements to maximize efficiency, effectiveness, and productivity in daily work activities

Makes recommendations to the Network Management and Application Optimization Manager on process improvements with the goal of enhancing quality and provider/member satisfaction

Qualification

Database managementManaged care experienceCredentialing standards knowledgeCloud-based applicationsStatistical reportingAnalytical skillsProcess improvementCommunication skillsOrganizational skillsInterpersonal skills