Provider Network Data Analyst I
Company: AmeriHealth Caritas Health Plan
Posted on: May 26, 2023
The Provider Network Data Analyst is responsible for supporting
the development of positive working relationships between Plan and
its contracted and non-contracted providers for all products,
Medicaid, Medicare and Exchange.The Provider Network Data Analyst I
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
- Demonstrates a working knowledge and ability to explain Plan
regulations, policies and procedures to providers.This requires the
Provider Data Analyst I to stay current with all updates and
- 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
- Maintaining a valid driver's license and current auto
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
- Effectively and professionally communicate to all parties
concerned the pertinent information required to execute quality
- Responsible for escalating requests contrary to established
business processes or contract language for resolution.
- Demonstrates a functional 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
- Supports, if requested, 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
- 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 functionally working knowledge of Facets,
including the provider database and routinely relays information
about additions, deletions or corrections to the Provider
- 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.
- Bachelor's Degree or equivalent work experience.
- Valid driver's license and current auto insurance.
- 1-2 years Medicaid experience preferred; 1 year in a Provider
- 3 years in the managed care/health insurance industry.
- Previous experience working with healthcare providers.
- Previous provider relations experience preferred.
Keywords: AmeriHealth Caritas Health Plan, Southfield , Provider Network Data Analyst I, Professions , Southfield, Michigan
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