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

Credentialing Specialist

Under the direction of the Network Management and Application Optimization Manager, this position performs and coordinates credentialing delegation functions for Sharp Health Plan in order to maintain a quality provider network. Serves as a liaison to delegated entities, the Credentialing Verification Office (CVO), vendors and internal Sharp Health Plan teams to ensure current and adequate credentialing processes are in place. Responsible for the maintenance of the provider database to ensure data integrity, including data accuracy, completeness, and consistency (standardization). Develops and performs database queries and abstracts for provider rosters, directories and statistical reporting on a frequent basis.

Required Qualifications

• Bachelor's degree healthcare management, business
• 2 years' 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 -PREFERRED

Other Qualification Requirements

• Other degree acceptable with a combination of education, managed care, and supervisorial experience.

Essential Functions

• Credentialing delegation oversightKnowledge of Department of Managed Care (DMHC), Knox Keene Act for regulations governing Health Maintenance Organizations (HMOs) and Department of Health Services (DHS) regulations regarding delegated services.Maintains current knowledge of delegation, contractual agreement(s), and reimbursement models.Maintains current knowledge of National Committee for Quality Assurance (NCQA), Department of Managed Health Care (DMHC), Industry Collaboration Effort (ICE), and Centers for Medicare and Medicaid Services (CMS) regulatory standards to ensure Sharp Health Plan credentialing processes meet all health plan contractual compliance requirements. Provides reporting, feedback and documentation, as necessary, to maintain compliance with delegated credentialing requirements.Works closely with the Credentialing Verification Organization (CVO) to manage deliverables as defined in the Sharp Health Plan / CVO delegation agreement.Responsible for review and ongoing monitoring of credentialing materials to ensure accurate and timely credentialing and re-credentialing of SHP providers within required regulatory timeframes.Responsible for plan medical group, group practice, and service ancillary credentialing delegation oversight activities through review of documents and preparation of reports applicable to the oversight process, and coordination with the CVO.Responsible for Health Delivery Organizations (HDO) facility credentialing delegation oversight to ensure adherence to NCQA and CMS standards.Conducts recredentialing review to include quality indicators such as member appeals, grievances and potential quality issues, working in collaboration with internal teams.Performs credentialing audits of delegated entities that perform credentialing functions according to their Sharp Health Plan delegation agreements to ensure compliance with Sharp Health Plan, NCQA, DMHC, CMS and other federal and state credentialing standards.Monitors compliance with corrective action plans. Works with accountable leaders to assure all action items are complete within required deadlines.Collaborates with the Medical Management and Network Management to obtain complete results of provider site audits.Prepares Peer Review Committee information summaries and presents relevant material at quarterly Peer Review Committee meetings.Prepares credentialing summaries for all practitioners meeting the Sharp Health Plan threshold criteria for "clean file" and "unclean file" review for presentation at monthly Peer Review Committee meetings.Responsible for maintaining timely, complete, accurate credentialing documentation in electronic format.Prepares accreditation information for submission and coordinates surveys for organization.Provides consultation on the development of guidelines, policies, procedures and protocols.Establishes and maintains processes to conduct annual review of delegate credentialing policies and procedures. Reviews for completeness and accuracy as it relates to regulatory standards.Develops and maintains policies and procedures for all credentialing and peer review processes in accordance with Sharp Health Plan, NCQA, DMHC, CMS, and other federal and state requirements.Participates in ICE workgroups related to credentialing activities to maintain policies and procedures in compliance with regulatory agencies.Attends internal and external meetings as appropriate.
• Customer serviceEstablishes good working relationships with providers, CVO contacts, medical directors, and all levels of internal and external customers.Demonstrates ability to be flexible and prioritize to meet the needs of the organization.Prepares clearly written and professional work products.Demonstrates cooperation and teamwork and assists others as needed. Accepts interpersonal differences and promotes cooperation with colleagues.Fosters open lines of communication and informs leadership of any issues relating to compliance or organizational risk.Coordinates and completes assigned projects as required.Performs other duties as assigned by the Network Management and Application Optimization, Manager.
• Database managementFamiliarity with basic principles of relational database management and elements of a database.Builds database queries and sets up job scheduling.Ensures the maintenance of the provider database and is responsible for reporting accurate information for required reports and provider directories.Experience developing and identifying processes by which reports are compiled using relational databases.Responsible for maintaining data integrity by systematically auditing database entries.Develops and maintains timely database policies and procedures.Identifies and takes action on IT upgrades to achieve database efficiencies, ease the burden of manual processes and implement department process improvements to maximize efficiency, effectiveness, and productivity in daily work activities.Analyzes database administration inefficiencies and streamlines processes accordingly.
• Statistical ReportingProduces and reviews statistical reports to monitor delegation oversight and network activities.Prepares complex charts and graphs to summarize and visualize report data on an as-needed basis.Responsible for validating the accuracy of statistical reporting, e.g., regulatory filings, dashboards, et al, based on database queries and abstracts.Tracks and 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.Compiles statistical reports, on a frequent basis, to demonstrate productivity and efficient workflow processes.
• Process improvementUtilizes a continuous quality improvement approach to identify and initiate department process improvements to maximize efficiency, effectiveness, and productivity in daily work activities.Makes recommendations to the Network Management and Application Optimization Manager on process improvements with the goal of enhancing quality and provider/member satisfaction.

Knowledge, Skills, and Abilities

• Excellent verbal and written communication skills.
• Excellent organizational skills with attention to detail.
• Strong analytical skills to evaluate, interpret and communicate data in a clear, concise manner.
• Excellent interpersonal skills.
• Ability to tactfully interact with the CVO, providers and their staff.
• Ability to define and prioritize tasks, manage workload and meet deadlines with minimal supervision.
• Thorough understanding of managed care principle, evolutions, and models.
• Familiarity with Department of Managed Health Care (DMHC) and DHS audit requirements as well as NCQA standards for delegation.
• Demonstrates courteous, professional, and cooperative behavior toward internal and external customers.
• Knowledge of NCQA, DMHC and CMS credentialing standards, legislative and regulatory requirements.
• Excellent computer skills, including proficiency in the MS Office Suite, including MS Excel, MS Word, MS PowerPoint, MS Access.
• Expert knowledge in cloud-based applications such as MS Teams, SharePoint, Smartsheet, etc.
• Ability to maintain peer review information confidentiality consistent with California Evidence Code 1157 for credentialing and peer review activities.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.