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

What You Will Do

• Perform and coordinate credentialing delegation functions for Sharp Health Plan.
• Serve as a liaison to delegated entities, the Credentialing Verification Office (CVO), vendors, and internal Sharp Health Plan teams.
• Maintain a quality provider network by ensuring current and adequate credentialing processes are in place.
• Maintain the provider database to ensure data integrity, including data accuracy, completeness, and consistency.
• Develop and perform database queries and abstracts for provider rosters, directories, and statistical reporting.

Required Qualifications

• Bachelor's degree in healthcare management or business.
• 2 years' experience in 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.

Essential Functions

• Oversee credentialing delegation, including knowledge of Department of Managed Care (DMHC), Knox Keene Act, and NCQA regulatory standards.
• Maintain compliance with Sharp Health Plan, NCQA, DMHC, CMS, and other federal and state credentialing standards.
• Manage deliverables as defined in the Sharp Health Plan / CVO delegation agreement.
• Review and monitor credentialing materials for accuracy and timeliness.
• Conduct recredentialing reviews and prepare reports for monthly Peer Review Committee meetings.
• Prepare and present credentialing summaries for "clean file" and "unclean file" reviews.
• Maintain timely, complete, and accurate credentialing documentation in electronic format.
• Prepare accreditation information and coordinate surveys.
• Develop and maintain policies and procedures for credentialing and peer review processes.
• Participate in ICE workgroups to maintain compliance with regulatory agencies.
• Attend internal and external meetings as appropriate.

Customer Service

• Establish good working relationships with providers, CVO contacts, medical directors, and all levels of internal and external customers.
• Demonstrate flexibility and prioritize tasks to meet organizational needs.
• Prepare clearly written and professional work products.
• Foster open communication and inform leadership of compliance issues.
• Coordinate and complete assigned projects as required.

Database Management

• Familiarity with basic principles of relational database management and elements of a database.
• Builds database queries and sets up job scheduling.
• Maintains data integrity by systematically auditing database entries.
• Develops and maintains timely database policies and procedures.
• Identifies and takes action on IT upgrades to improve efficiency and productivity.
• Analyzes database administration inefficiencies and streamlines processes.

Statistical Reporting

• Produces and reviews statistical reports to monitor delegation oversight and network activities.
• Compiles statistical reports on a frequent basis to demonstrate productivity and efficient workflow processes.
• Validates the accuracy of statistical reporting based on database queries and abstracts.
• 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.
• Makes recommendations to enhance quality and provider/member satisfaction.