HSCSN Provider Data Specialist

Minimum Education High School Diploma or GED (Required) Bachelor's Degree Business, Health Care Management, Health Care Administration, or Information Technology (Preferred) Minimum Work Experience 3 years 1. A minimum of three (3) years prior experience working with managed care and/or health care setting. (Required) 1 year 2. Prior experience in working with provider and health plan data sets required. 3. Knowledge of claims, network development, provider network operations, provider relationship management, and provider demographic data sets and identifiers, required. 4. Knowledge of Medicaid and other State and Federal mechanisms, i.e., claims processing, UM programs, provider contract administration, NCQA, HEDIS, required. 5. Excellent public presentation, negotiation, stakeholder facilitation, time management, problem solving, analytical, organizational, written, and verbal skills are essential. (Required) 1 year 6. General knowledge of legislative and government activities and marketplace issues affecting the region, preferred. 7. Experience with developing and implementing provider data quality processes, highly preferred. 8. Medium to high-level proficiency in Microsoft Word, Excel, Access, and Visio, required. SQL, high desirable (Preferred) Job Functions 1. Manages the provider add/change process and ensures the timely update and entry of provider demographic data within core health plan systems (i.e., QNXT claims systems, Guiding Care utilization management and CM systems). Adheres to system requirements and standards as it relates to provider data completeness and accuracy. 2. Ensures the appropriate and accurate entry of provider data 3. Develops tracking reporting, and metrics for provider add/change information. 4. Supports regulatory reporting related to provider add/change activity. 5. Develops quality assurance process and conducts quality review. Develops plan for data corrections, where needed. 6. Analyzes provider data quality across Health Plan systems. Identifies gaps and/or data misalignment and makes the appropriate updates and corrections, as needed. 7. Develops and leads audit processes with the Provider Network Team and cross-functionally, as needed. 8. Supports provider /add change process as it relates to roster update process received from provider delegates. 9. Supports provider data strategies and initiatives as it relates to health plan system implementations and/or expanded system functionality. 10. Supports and manages the provider file and process as it relates to the online and published Provider Directories. 11. Works closely with the Provider Network Team and other Health Plan Teams to develop business requirements related to provider data management automation and/or reporting, as needed or required. 12. Ensures proper loading of provider demographic information to support the accurate, technical implementation of HSCSN Provider contracts. Other job duties1. May perform other duties in addition to those outlined in this job description. Organizational Accountabilities Organizational Accountabilities (Staff) Employee Excellence Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved Innovates through improvement of care and/or efficiency of operational processes. Dedicated to a standard of performance excellence and high quality All In Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency Identifies, prioritizes and selects alternative solutions to determine best outcome Action Oriented Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands Anticipates problems and attempts to solve before they develop Supervisory Responsibilities Blood Borne Pathogen Exposure Protected Health Information Access Level Working Environment Physical Requirements Travel Requirements Minimum Education High School Diploma or GED (Required) Bachelor's Degree Business, Health Care Management, Health Care Administration, or Information Technology (Preferred) Minimum Work Experience 3 years 1. A minimum of three (3) years prior experience working with managed care and/or health care setting. (Required) 1 year 2. Prior experience in working with provider and health plan data sets required. 3. Knowledge of claims, network development, provider network operations, provider relationship management, and provider demographic data sets and identifiers, required. 4. Knowledge of Medicaid and other State and Federal mechanisms, i.e., claims processing, UM programs, provider contract administration, NCQA, HEDIS, required. 5. Excellent public presentation, negotiation, stakeholder facilitation, time management, problem solving, analytical, organizational, written, and verbal skills are essential. (Required) 1 year 6. General knowledge of legislative and government activities and marketplace issues affecting the region, preferred. 7. Experience with developing and implementing provider data quality processes, highly preferred. 8. Medium to high-level proficiency in Microsoft Word, Excel, Access, and Visio, required. SQL, high desirable (Preferred) Job Functions 1. Manages the provider add/change process and ensures the timely update and entry of provider demographic data within core health plan systems (i.e., QNXT claims systems, Guiding Care utilization management and CM systems). Adheres to system requirements and standards as it relates to provider data completeness and accuracy. 2. Ensures the appropriate and accurate entry of provider data 3. Develops tracking reporting, and metrics for provider add/change information. 4. Supports regulatory reporting related to provider add/change activity. 5. Develops quality assurance process and conducts quality review. Develops plan for data corrections, where needed. 6. Analyzes provider data quality across Health Plan systems. Identifies gaps and/or data misalignment and makes the appropriate updates and corrections, as needed. 7. Develops and leads audit processes with the Provider Network Team and cross-functionally, as needed. 8. Supports provider /add change process as it relates to roster update process received from provider delegates. 9. Supports provider data strategies and initiatives as it relates to health plan system implementations and/or expanded system functionality. 10. Supports and manages the provider file and process as it relates to the online and published Provider Directories. 11. Works closely with the Provider Network Team and other Health Plan Teams to develop business requirements related to provider data management automation and/or reporting, as needed or required. 12. Ensures proper loading of provider demographic information to support the accurate, technical implementation of HSCSN Provider contracts. Other job duties1. May perform other duties in addition to those outlined in this job description. Organizational Accountabilities Organizational Accountabilities (Staff) Employee Excellence Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved Innovates through improvement of care and/or efficiency of operational processes. Dedicated to a standard of performance excellence and high quality All In Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency Identifies, prioritizes and selects alternative solutions to determine best outcome Action Oriented Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands Anticipates problems and attempts to solve before they develop Supervisory Responsibilities Blood Borne Pathogen Exposure Protected Health Information Access Level Working Environment Physical Requirements Travel Requirements

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