HSCSN Provider Data Specialist

HSCSN Provider Data Specialist Salary: 260,000 RM Job Description The Provider Data Specialist is responsible for the management of the HSCSN Network provider data. This includes the capture and processing of provider demographic information related to HSCSN Network Providers within health plan systems (i.e., credentialing, claims, utilization management, and care management systems), management of the online and published provider directories as well as the ongoing monitoring/quality review process. The Provider Data Specialist employs an analytical approach for quality assurance, drives business requirements toward opportunities to automate, leads the audit process of provider network data, and ensures the timely upload of provider data relative to new HSCSN provider contracts as well as changes to existing provider contracts and panels. Qualifications Minimum Education High School Diploma or GED (Required) Bachelor's Degree in Business, Health Care Management, Health Care Administration, or Information Technology (Preferred) Minimum Work Experience Minimum of three (3) years prior experience working with managed care and/or health care setting. (Required) Prior experience working with provider and health plan data sets. (Required) Knowledge of claims, network development, provider network operations, provider relationship management, and provider demographic data sets and identifiers. (Required) Knowledge of Medicaid and other state and federal mechanisms, i.e., claims processing, UM programs, provider contract administration, NCQA, HEDIS. (Required) Excellent public presentation, negotiation, stakeholder facilitation, time management, problem solving, analytical, organizational, written, and verbal skills. (Required) General knowledge of legislative and government activities and marketplace issues affecting the region. (Preferred) Experience with developing and implementing provider data quality processes. (Highly Preferred) Medium to high-level proficiency in Microsoft Word, Excel, Access, and Visio. (Required). SQL proficiency highly desirable. (Preferred) Job Functions Manages the provider add/change process and ensures timely update and entry of provider demographic data within core health plan systems. Ensures appropriate and accurate entry of provider data. Develops tracking reports and metrics for provider add/change information. Supports regulatory reporting related to provider add/change activity. Develops quality assurance processes and conducts quality reviews, implementing plans for data corrections. Analyzes provider data quality across Health Plan systems, identifying gaps and misalignments, and making appropriate updates and corrections as needed. Develops and leads audit processes with the Provider Network Team and cross-functions. Supports provider add/change process related to roster update process received from provider delegates. Supports provider data strategy and initiatives related to health plan system implementations or expanded system functionality. Supports and manages provider file and processes related to the online and published Provider Directories. Works closely with the Provider Network Team and other Health Plan Teams to develop business requirements related to provider data management automation or reporting. Ensures proper loading of provider demographic information to support accurate technical implementation of HSCSN Provider contracts. May perform other duties in addition to those outlined. Organizational Accountabilities Employee Excellence Demonstrates understanding of quality of service and collaborates with co‑workers to ensure standards are achieved. All In Embraces changes/improvements and actively participates in implementation of 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 high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands. Anticipates problems and attempts to solve before they develop. Primary Location District of Columbia – Washington Work Location HSCSN – 1101 Vermont Ave NW, Washington, DC 20005 Position Status Regular – Full Time Shift Day Work Schedule Mon-Fri 8:30–5:00 Salary Range 54,516.8 – 90,854.4 Equal Opportunity Employer Health Services for Children with Special Needs (HSCSN) is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law. The “Know Your Rights” poster is available here, and the pay transparency policy is available here. Pay Transparency: Nondiscrimination Poster. Please note that it is the policy of Health Services for Children with Special Needs (HSCSN) to ensure a “drug-free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances by all staff (management, employees and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug-free workplace, including prohibiting recreational or prescribed marijuana. #J-18808-Ljbffr