Provider Data Management Resolution Analyst

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

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Job Summary:

The Provider Data Management Resolution Analyst acts as a liaison between providers and the organization in both the claims and credentialing areas. This role assists with escalated provider issues through providing research and follow up to involved parties. Position evaluates all presented applicant information for initial and re-credentialing, directing, and overseeing primary source verification, and ensuring clarification of any discrepancies discovered in the verification process. Position accurately summarizes and reports the results of each investigation to the Medical Director and Plan Credentialing Committee, with written follow-up regarding credentialing determinations, as required. Position also ensures processes demonstrate compliance with State, Federal and National regulatory requirements, and the accreditation standards of the National Committee for Quality Assurance (NCQA) and Medicare (CMS). Position supports all aspects of Provider Data management to ensure the providers data is accurately captured in the claims processing system.

Job Duties/Responsibilities:

• Manages and clearly responds to providers, their liaisons, leadership, doctors, and internal inquiries via provider web portals shared mailboxes, provider data management, credentialing and contracting shared mailboxes.
• Manages service ticket requests submitted to LaserFiche for resolution, following up to ensure timely closure.
• Responsible for monitoring and coordinating the completion of Health Plan practitioner and allied health professionals credentialing applications.
• Manages information and updates to appropriate issue tracking logs (SmartSheet) to ensure incoming complaints/requests are tracked, closed, and monitored for past due issues.
• Creates weekly Provider Compliant Report for Commercial and MA, as well as any new reports to satisfy regulatory compliance or departmental needs.
• Supports Provider Relations Representatives to resolve questions, and escalated calls.
• Maintains data integrity of all credentialing software programs through accurate and timely data entry
• Works collaboratively with Customer Services Resolution Specialist and Claims Resolution Specialist to resolve provider claims processing disputes.
• Promotes world class customer service for internal and external customers.
• Report escalated issues that need further evaluation to the Director, Operations.
• Analyzes trends, identifies problems, and issues and brings forth proposed resolutions including provider training.
• Reports provider issues to assigned Provider Relations Representative.
• Consistently demonstrates and maintains appropriate effective professional communications with internal department, providers and provides timely follow up as needed.
• Enters, updates, and maintains data from provider applications into claims processing databases, focusing on accuracy, and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures
• Communicates clearly with providers, their liaisons, leadership, and doctors, as needed to provide timely responses upon request on day-to-day credentialing and claims issues as they arise.
• Monitor expiring licensure, board, and professional certifications and other expirable documents with practitioners within the prescribed timeframe.
• Communicate with provider, practice manager or contract signatory to receive active current licensure for providers unable to verify via credentialing platform.
• Initiate provider terminations for credentialing non-compliance.
• Actively participate in team meetings and process improvement initiatives to continuously improve work efficiency.
• Coordinates timely collection and integration of selected performance monitoring activities and follows up as needed (i.e., office visit requests, member complaint reports, quality improvement activity reports, etc.).
• Process all provider and group terminations within departmental turnaround guidelines
• Support LaserFiche application and workflow and provide insight to process improvement and efficiencies.
• Support network management with day-to-day operations, identify areas for improvement related to internal and external provider operations.
• Performs special projects as assigned by the management.

Benefit Highlights:

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! · More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

Qualifications and Requirements:

• High school diploma: Associates degree or equivalent work experience preferred
• Minimum of 6 months experience in working with provider data and credentialing functions
• 3 years customer service with ability to handle challenging customer situations in a professional manner.
• Knowledge of QNXT claims processing system
• Knowledge of Provider and Credentialing terminology
• Ability to interpret health plan benefits and provider contracts.
• Excellent computer skills which must include proficiency in Microsoft Office Suite with emphasis on Excel and Power Point.
• Excellent English communication skills with an ability to communicate complex program criteria into easily understood summaries both orally and written
• Proficient critical-thinking and analytical problem-solving skills
• Identify, recommend, and implement processes that improve quality, increases productivity, reduces waste, costs, and rework resulting in business improvement and customer satisfaction.
• Ability to interpret and apply established policies and procedures.
• Must be a team player and ability to work independently with little supervision

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

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