Job Description
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 tot his job