Senior Demographic Analyst

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience.  Some of our offerings include:

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

• Annual incentive bonus plan based on company achievement of goals

• Time away from work including paid holidays, paid time off and volunteer time off

• Professional development courses, mentorship opportunities, and tuition reimbursement program

• Paid parental leave and adoption leave with adoption financial assistance

• Employee discount program

Job Description Summary:

The BlueKC Demographics Analyst, Sr plays a crucial role in maintaining accurate and comprehensive provider information within the health plan's systems. This individual is responsible for a wide range of duties related to provider data management, ensuring compliance with regulatory requirements, facilitating efficient claims processing, and supporting overall network operations. This role requires a high level of expertise and the ability to work independently to resolve complex issues and support departmental goals. 

Job Description

Provider Data Management: 

• Oversees and maintains accurate provider demographic information in the sPayer and Facets platforms by ensuring data integrity and consistency across all systems feeds. 
• Processes new provider setups, updates, and terminations, including managing the entire lifecycle of provider records. 

Compliance & Auditing: 

• Ensures compliance with state and federal regulations, including those related to provider enrollment, credentialing, directory, and data accuracy. 
• Conducts regular audits of provider data to identify and resolve discrepancies, ensuring adherence to quality standards. 
• Updates delegated provider rosters monthly and on an ad hoc basis to maintain state compliance. 

Problem Resolution & Support: 

• Serves as a primary liaison between the health plan departments and providers, resolving complex inquiries and addressing network-related issues. 
• Provides direct support and oversight for trouble shooting and resolution of Blue Provider Data submission issues related to data quality. 
• Collaborates with internal departments (e.g., Contracting, Credentialing, Provider Relations) to resolve provider inquiries and contractual disputes. 
• Provides support and guidance to less experienced team members, acting as a subject matter expert in provider data management processes. 

Reporting & Analysis: 

• Generates reports and statistical data for management review, follow-up, and resolution. 
• Analyzes provider data to identify trends, potential issues, and opportunities for process improvement. 
• Presents findings and insights to management, collaborating on solutions to enhance efficiency and metrics. 

Workflow Optimization: 

• Actively participate in project implementation and process improvement initiatives to streamline department operations. 
• Develops and implements strategies to optimize data collection and management for improved efficiency and accuracy.  
• Creates and maintains automated process flows ensuring that downstream databases for contract provider networks, prior authorization, and third-party liability are accurate. 

Minimum Qualifications

• Bachelor's degree in healthcare administration, health information management, or an equivalent combination of education and experience
• 5+ years of experience working with managed care or the healthcare industry, with a focus on provider data or network administration. 
• Familiarity with relevant healthcare industry regulations and systems, such as HIPAA, FACETS, NPPES, PEGA, NCQA, ICE, DMHC, DHCS, and CMS. 
• Proficiency in Microsoft Office Suite, including Access and Excel. 
• Strong understanding and experience with database management systems and reporting tools. 
• Excellent written and verbal communication skills. 
• Strong analytical and problem-solving skills, with keen attention to detail and accuracy. 
• Ability to work independently, manage multiple priorities, and meet deadlines. 
• Strong organizational and time management skills. 
• Ability to collaborate effectively with internal and external stakeholders 

Preferred Qualifications

• Preferred use of sPa