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

Hours and Pay Range

Hours: Shift Start Time: 8 AM Shift End Time: 5 PM AWS Hours Requirement: 8/40 - 8 Hour Shift Additional Shift Information: Weekend Requirements: No Weekends On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $32.73 - $40.91 - $45.81

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

Please Note

As part of our recruitment process, you may receive communication from Dawn, our virtual recruiting assistant. Dawn helps coordinate scheduling for screening calls and interviews to ensure a smooth and timely experience. Rest assured, all candidate evaluations and hiring decisions are made by our recruitment and hiring teams.

Job Summary

Under the direction of the Network Management and Application Optimization, Manager, this position performs and coordinates credentialing delegation functions for Sharp Health Plan in order to maintain a quality provider network. Serves as a liaison to delegated entities, the Credentialing Verification Office (CVO), vendors and internal Sharp Health Plan teams to ensure current and adequate credentialing processes are in place.

Responsibilities

• Responsible for the maintenance of the provider database to ensure data integrity, including data accuracy, completeness, and consistency (standardization).
• Develops and performs database queries and abstracts for provider rosters, directories and statistical reporting on a frequent basis.
• 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.

Required Qualifications

• Bachelors degree in healthcare management, business
• 2 years experience in managed care field
• 3 years experience in database management
• 1 year experience in cloud-based credentialing database applications such as MD-Staff or other similar solutions
• Certified Provider Credentialing Specialist (CPCS) - National Association Medical Staff Services

Preferred Qualifications

• Other degree acceptable with a combination of education, managed care, and supervisorial experience

Essential Functions

• 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 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
• 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

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

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

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

Knowledge, Skills, and Abilities

• Excellent verbal and written communication skills
• Excellent organizational skills with attention to detail
• Strong analytical skills to evaluate, interpret and communicate data in a clear, concise manner
• Excellent interpersonal skills
• Ability to tactfully interact with the CVO, providers and their staff
• Ability to define and prioritize tasks, manage workload and meet deadlines with minimal supervision
• Thorough understanding of managed care principle, evolutions, and models
• Familiarity with Department of Managed Health Care (DMHC) and DHS audit requirements as well as NCQA standards for delegation
• Demonstrates courteous, professional, and cooperative behavior toward internal and external customers
• Knowledge of NCQA, DMHC and CMS credentialing standards, legislative and regulatory requirements
• Excellent computer skills, including proficiency in the MS Office Suite, including MS Excel, MS Word, MS PowerPoint, MS Access
• Expert knowledge in cloud-based applications such as MS Teams, SharePoint, Smartsheet, etc.
• Ability to maintain peer review information confidentiality consistent with California Evidence Code 1157 for credentialing and peer review activities

Sharp HealthCare

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class