Prov Network Data Analyst II
Location: Detroit, MI
Primary Job Function: Medical Management
ID**: 28080
Your career starts now. We're looking for the next generation of health care leaders.
At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .
The primary purpose of the job is to:The Provider Network Data Analyst II is responsible for building, and maintaining positive working relationships between Plan and its contracted and non-contracted providers for all products, Medicaid, Medicare and Exchange. The Provider Network Data Analyst II 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 Account Executive 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
Coach, provide feedback, and guide Provider Network Data Analysts
Facilitate training new associates
Serve as a key resource on complex and / or critical issues
Develops tools and reports that lend valuable insights that capitalize on a combination of internal and external data
Evaluate departments adherence to the service level goals including volume, processing, timeliness, accuracy and other metrics
Serve on various committees and attends required meetings on behalf of Provider Network Management
Facilitates and conducts meetings in supervisors absence
Maintains a 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 solid 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 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 solid 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.
3 to 5 years Medicaid experience preferred.
3 to 5 years in a Provider Data Management position.
5 to 10 years in the managed care/health industry.
Previous experience working with healthcare providers.
Previous provider relations experience preferred.
EOE Minorities/Females/Protected Veterans/Disabled