Demographic Analyst-Provider Data -REMOTE
Job Summary
The Senior Demographics Analyst plays a crucial role in maintaining accurate and comprehensive provider information within the health plan's systems. This individual is responsible for a wide range of duties related to provider data management, ensuring compliance with regulatory requirements, facilitating efficient claims processing, and supporting overall network operations. This role requires a high level of expertise and the ability to work independently to resolve complex issues and support departmental goals.
Primary Responsibilities
Provider Data Management:
• Oversees and maintains accurate provider demographic information in the sPayer and Facets platforms by ensuring data integrity and consistency across all systems feeds.
• Processes new provider setups, updates, and terminations, including managing the entire lifecycle of provider records.
Compliance & Auditing:
• Ensures compliance with state and federal regulations, including those related to provider enrollment, credentialing, directory, and data accuracy.
• Conducts regular audits of provider data to identify and resolve discrepancies, ensuring adherence to quality standards.
• Updates delegated provider rosters monthly and on an ad hoc basis to maintain state compliance.
Problem Resolution & Support:
• Serves as a primary liaison between the health plan departments and providers, resolving complex inquiries and addressing network-related issues.
• Provides direct support and oversight for trouble shooting and resolution of Blue Provider Data submission issues related to data quality.
• Collaborates with internal departments (e.g., Contracting, Credentialing, Provider Relations) to resolve provider inquiries and contractual disputes.
• Provides support and guidance to less experienced team members, acting as a subject matter expert in provider data management processes.
Reporting & Analysis:
• Generates reports and statistical data for management review, follow-up, and resolution.
• Analyzes provider data to identify trends, potential issues, and opportunities for process improvement.
• Presents findings and insights to management, collaborating on solutions to enhance efficiency and metrics.
Workflow Optimization:
• Actively participate in project implementation and process improvement initiatives to streamline department operations.
• Develops and implements strategies to optimize data collection and management for improved efficiency and accuracy.
• Creates and maintains automated process flows ensuring that downstream databases for contract provider networks, prior authorization, and third-party liability are accurate
Education and Experience
• Bachelor's degree in healthcare administration, health information management, or an equivalent combination of education and experience
• 5+ years of experience working with managed care or the healthcare industry, with a focus on provider data or network administration.
• Preferred use of sPayer, Facets, and/or sProvider systems
• Proficiency in Microsoft Office Suite, including Access and Excel.
• Strong understanding and experience with database management systems and reporting tools.
• Familiarity with relevant healthcare industry regulations and systems, such as HIPAA, FACETS, NPPES, PEGA, NCQA, ICE, DMHC, DHCS, and CMS.
• Excellent written and verbal communication skills.
• Strong analytical and problem-solving skills, with keen attention to detail and accuracy.
• Ability to work independently, manage multiple priorities, and meet deadlines.
• Strong organizational and time management skills.
• Ability to collaborate effectively with internal and external stakeholders
Apply Now
Apply Now
The Senior Demographics Analyst plays a crucial role in maintaining accurate and comprehensive provider information within the health plan's systems. This individual is responsible for a wide range of duties related to provider data management, ensuring compliance with regulatory requirements, facilitating efficient claims processing, and supporting overall network operations. This role requires a high level of expertise and the ability to work independently to resolve complex issues and support departmental goals.
Primary Responsibilities
Provider Data Management:
• Oversees and maintains accurate provider demographic information in the sPayer and Facets platforms by ensuring data integrity and consistency across all systems feeds.
• Processes new provider setups, updates, and terminations, including managing the entire lifecycle of provider records.
Compliance & Auditing:
• Ensures compliance with state and federal regulations, including those related to provider enrollment, credentialing, directory, and data accuracy.
• Conducts regular audits of provider data to identify and resolve discrepancies, ensuring adherence to quality standards.
• Updates delegated provider rosters monthly and on an ad hoc basis to maintain state compliance.
Problem Resolution & Support:
• Serves as a primary liaison between the health plan departments and providers, resolving complex inquiries and addressing network-related issues.
• Provides direct support and oversight for trouble shooting and resolution of Blue Provider Data submission issues related to data quality.
• Collaborates with internal departments (e.g., Contracting, Credentialing, Provider Relations) to resolve provider inquiries and contractual disputes.
• Provides support and guidance to less experienced team members, acting as a subject matter expert in provider data management processes.
Reporting & Analysis:
• Generates reports and statistical data for management review, follow-up, and resolution.
• Analyzes provider data to identify trends, potential issues, and opportunities for process improvement.
• Presents findings and insights to management, collaborating on solutions to enhance efficiency and metrics.
Workflow Optimization:
• Actively participate in project implementation and process improvement initiatives to streamline department operations.
• Develops and implements strategies to optimize data collection and management for improved efficiency and accuracy.
• Creates and maintains automated process flows ensuring that downstream databases for contract provider networks, prior authorization, and third-party liability are accurate
Education and Experience
• Bachelor's degree in healthcare administration, health information management, or an equivalent combination of education and experience
• 5+ years of experience working with managed care or the healthcare industry, with a focus on provider data or network administration.
• Preferred use of sPayer, Facets, and/or sProvider systems
• Proficiency in Microsoft Office Suite, including Access and Excel.
• Strong understanding and experience with database management systems and reporting tools.
• Familiarity with relevant healthcare industry regulations and systems, such as HIPAA, FACETS, NPPES, PEGA, NCQA, ICE, DMHC, DHCS, and CMS.
• Excellent written and verbal communication skills.
• Strong analytical and problem-solving skills, with keen attention to detail and accuracy.
• Ability to work independently, manage multiple priorities, and meet deadlines.
• Strong organizational and time management skills.
• Ability to collaborate effectively with internal and external stakeholders
Apply Now
Apply Now