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

Responsibilities

• Required Qualifications
• Bachelor's degree healthcare management, business
• 2 years' database management.
• 3 years' experience in managed care field.

Requirements

• 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 oversight
• Knowledge 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.
• 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 re

Benefits

Additional Information

Hours : Shift Start Time: 8 AM Shift End Time: 5 PM AWS Hours Requirement: 8/40 - 8 Hour Shift Additional Shift Information: Weekend Requirements: No Weekends On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $32.730 - $40.910 - $45.810 The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

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