The Provider Network Data Analyst is responsible for supporting the development of positive working relationships between Plan and its contracted and non-contracted providers for all products, Medicaid, Medicare and Exchange. The Provider Network Data Analyst I ensures that providers’ status with the health plan is represented correctly in all plan operating systems, functions as a pro-active practice account leader and coordinates resolution of provider issues

• Demonstrates a working knowledge and ability to explain Plan regulations, policies and procedures to providers. This requires the Provider Data Analyst I to stay current with all updates and revisions.
• Responsible for Monitoring and Managing Provider Network by assuring appropriate access to services throughout the Plan’s territory in keeping with State contract mandates.
• Responsible for provider data management
  • Maintaining a valid driver’s license and current auto insurance
    provider data change database documenting and tracking requests and monitoring processing turnaround time.
  • Responsible for data intake process including knowledge of relevant systems required to complete job functions.
  • Responsible for reviewing the data intake forms for accuracy and completeness.
  • Effectively and professionally communicate to all parties concerned the pertinent information required to execute quality services.
  • Responsible for escalating requests contrary to established business processes or contract language for resolution.
  • Demonstrates a functional knowledge of provider data and managed care provider reimbursement methodologies.
  • Knowledge of Managed Care concepts
  • Demonstrates ability to work independently.
  • Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas, assuring financial integrity of the Plan is maintained and Contract Management requirements are adhered to including language, terms and reimbursement requirements
  • Responsible for the accuracy and timely management of the provider contracts
• Supports, if requested, the credentialing and re-credentialing process, and the investigation of member complaints.
  • Completes requests for initial site visits within time period specified by Department standards. This includes requests for review of an existing participating physician’s new office location.
  • Submits completed site visit forms to the Credentialing Department within time period specified by Department standards.
  • Obtains documentation required for credentialing for credentialing or re-credentialing of providers as requested.
  • Completes requests for investigation of member complaints within time period specified by Department standards.
  • Identifies and reports compliance issues in accordance with Plan policy and procedure.
• Demonstrates a functionally working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department.
• Works with all departments to develop and execute strategies for optimally managing medical costs.
• Administrative responsibilities:
  • Performs other duties and projects as assigned.
  • Adheres to Plan policies and procedures.
  • Attends required training sessions on an annual basis.

Education/ Experience:

• Bachelor’s Degree or equivalent work experience.
• Valid driver’s license and current auto insurance.
• 1-2 years Medicaid experience preferred; 1 year in a Provider Services position.
• 3 years in the managed care/health insurance industry.
• Previous experience working with healthcare providers.
• Previous provider relations experience preferred.