PROVIDER DATA AND CREDENTIALING ANALYST

JOB PURPOSE:

Reporting to the Manager, Provider Data Management, Credentialing & Analytics, the Provider Data and Credentialing Analyst supports the management and maintenance of CenterLight Healthcare’s provider network data, and credentialing, for its integrity and its compliance. This role will be responsible for the processing and managing of network provider data, including credentialing, system updates, network analyses, DOH reporting (PNDS), ad-hoc internal reporting, external reporting, and quality assurance/auditing.

JOB RESPONSIBILITIES:

Provider Data:

• Collaborate with Provider Relations in network data collection, standardization, and management.
• Timely data file processing for system uploads based on contracted provider files and contracts.
• Perform data entry to Care Compass, provider data and claims management system. Ensure accuracy and timeliness.
• Manage confidential information of internal staff (Physicians, Nurse Practitioners).
• Triage regular and troubleshoot ad-hoc provider network data/system cleaning, loading, and reporting requests for internal and external stakeholders.
• Completes and submits a complete and accurate Provider Network Data Submission (PNDS) report quarterly.
• Support file transfers to third party vendors.
• Develop and conduct data validation processes and data auditing with responsibility for process improvement strategies.
• Perform preclusion, exclusion, and other sanction list processing to ensure network compliance.
• Maintain a record of inaccuracies and follow-up on sensitive information with providers.
• Develop and maintain rolling issues list.
• Support provider network oversight processes (e.g., maintaining network adequacy, regular and ad-hoc audits, etc.).
• Highlight system and process issues and support remediation efforts through problem-solving, tool development, etc.

Credentialing:

• Perform credentialing and recredentialing process for the entire CL network providers.
• Perform credentialing through CAQH for physicians and specialists. Complete the check list requirements, including follow-up with providers.
• Perform credentialing for non-CAQH providers, including non-licensed providers, such as LHCSAs, SNFs, Portable X Ray providers, Home Health Agencies (HHAs); Clinical laboratories (a CMS-issued CLIA certificate or a hospital-based exemption from CLIA); DME and OTC providers, based on the required policy and procedures, documents all finding and follow-up with providers.
• Perform validation for network providers requesting delegated credentialing privileges, ensure its meet regulatory and CenterLight credentialing program requirements.
• Assist in providing information for regulatory and internal audits as needed.
• Ensures credentialing database and all providers documents are maintained to ensure accuracy of provider directory and network reports.
• Prepare documents for Credentialing Committee review.
• Provide productivity and issues reports for Management.
• Remain current on policies affecting provider credentials and enrollment processes.
• Work with sensitive or proprietary information with discretions and professional judgment for different internal and external stakeholders.

• Perform other responsibilities as assigned.

Schedule: 8:30AM – 5:30PM, hybrid 2-3 days in the Bronx Wallerstein office with days in the office as assigned.

Weekly Hours: 40

QUALIFICATIONS:

Education:

• Bachelor’s degree or equivalent experience in healthcare administration, public health, systems information, or other quantitative fields, such as Finance.

Experience:

• 1-3 Years of data management, data operations/analytics, quality, process improvement, and project management skills required.
• Provider credentialing experience is strongly preferred.
• Working knowledge of Medicare and Medicaid is required.
• Ability to efficiently standardize and reconcile disparate data effectively.
• Advanced Microsoft Excel skills required.
• Effective oral, written, and interpersonal communication skills are required.
• Health plan/managed care setting, preferred.
• Proficient in Microsoft Office applications with advanced Excel skills.

• Detail-oriented and effective communicator, professional and collaborative, a great team player.
• Discretion with highly sensitive information, including credentialing files, sanction lists, claims, and remittance information.
• Able to multitask efficiently, effectively, and timely.
• Strong organizational skills and work ethic.
• Customer service experience.