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

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):

$32.730 - $40.910 - $45.810

 

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.

What You Will Do
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. 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.

Required Qualifications

• Bachelor's degree healthcare management, business
• 2 years' database management.
• 3 years' experience in managed care field.

Preferred Qualifications

• 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

Other Qualification Requirements

• 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 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 provi