Overview

The Provider Data Management Specialist 3 will perform the end-to-end processes necessary to ensure the contract and demographic data required to implement and operationalize external provider contracts is accurately captured in source systems. Accountable for collection, analysis, validation, and set up of contract data elements, provider information, and practitioner demographics to support contracting, claims payment, credentialing, referrals, regulatory and network adequacy reporting, and directory display.

Manages outreach needed to ensure all contracted provider data is accurately maintained within the defined business rules, data quality standards and regulatory timelines. The accuracy and timeliness of securing and maintaining provider contract demographic information in KP's source systems is critically important in order for KP to comply with requirements of Federal and State regulators, employer groups who purchase KP health insurance products for their employees, Members/consumers to have transparency to those providers available to them in KP's networks, and to ensure claims can be processed accurately and timely in accordance with applicable contract terms.

This position will function as a liaison between providers, contract managers, contract coordinators, systems teams, and credentialing staff as well as other related departments to ensure data integrity, error resolution, and process improvement.

Join our medical group

Northwest Permanente is a self-governed, physician-led, multi-specialty group of 1,500 physicians, surgeons, and clinicians, caring for 630,000 members in Oregon and Southwest Washington. Kaiser Permanente is one of the nation's preeminent health care systems, a benchmark for comprehensive, integrated, value-based, and high-quality care.

Responsibilities

Major Responsibilities / Essential Functions

• Perform contract and data analysis to ensure provider data is correctly configured into systems.
• Create, research, extract, analyze, and solve complex provider data management issues to ensure provider data is correctly configured into source systems.
• Build and maintain effective partnerships with contracted practitioners, provider groups, hospital and facility organizations to research and collect required data elements needed to implement provider contracts.
• Position accountable for maintaining provider demographic and contract data for complex health system and large medical group practices.
• Demonstrate analytical and problem-solving skills to research and resolve data discrepancies and data integrity issues within required timeframe.
• Act as a consultant on the programming of SAS code used to automate the retrieval of provider data; test the SAS code configuration parameters to ensure the program is functioning correctly and launch SAS programs for Professional and Facility Outreach.
• Conduct provider data integrity audits, monitoring, and analysis in accordance with provider contracts, system configuration, and regulatory requirements.
• Develop, document, implement, and maintain business rules, systematic workflows, and policies and procedures to guide data setup and ensure the source system effectively captures the required data elements.
• Lead and manage special projects related to provider data remediation and data quality.
• Track and report team performance relating to provider directory and regulatory reporting requirements and timelines.
• Contribute in regional, interregional, and national workgroups and community of practice groups related to provider data maintenance.

• Interpret, organize, capture and setup contract data, provider information and practitioner demographics into source systems within defined business rules, data architecture, and regulatory requirements.

• Validate data elements submitted by provider on verification websites to meet data integrity standards.
• Work closely with Quality Resource Management Department to initiate credentialing and organization assessments.
• Proactively communicate and engage contracted providers to ensure timely receipt and accurate processing of provider data updates including processing practitioner roster additions, terminations, and practice location changes, updated W9s, pay to locations, ownership changes.
• Triage provider data intake, document, and respond timely to provider inquires; phone calls, emails, related to provider data and practitioner demographics.
• Apply knowledge of requirements from federal and state regulator including network adequacy and directory reporting.
• Develop and maintain high level of data integrity and quality assurance standards.
• Collaborate between external provider representatives/stakeholders and internal stakeholders including
• Provider Contract Managers, National Claims Administration, Quality Resource Management, Referral Center, Network Adequacy Program, Provider Data Technical Teams to respond to inquiries related to provider data.
• Perform general administrative tasks to support contracting and provider data management needs.

Qualifications

Minimum Education

• Bachelors degree in business administration or related field, or equivalent combination of education and experience

Minimum Work Experience

• Minimum four (4) years of experience in a position requiring professional written and oral communication skills
• Minimum Five (5) years of experience processing contracted provider demographic data within a managed care organization applying knowledge and experience to ensure information is accurately captured and maintained to allow for critical downstream functions (claims processing, network adequacy reporting and directory processes)
• Two (2) years in the health care industry
• Two (2) years of experience managing and analyzing large volumes of data

Additional Requirements

• Experience with systems migration and implementation
• Proficiency with computer software programs such as MS Excel, MS Word, MS Access to organize and communicate information. Ability to quickly learn new information systems and software programs.
• Must possess strong analytical and problem-solving skills
• Thorough knowledge and experience with multiple data collection techniques and data quality control
• Excellent written and verbal communication skills
• Attention to detail and excellent organizational skills
• Ability to prioritize and manage multiple tasks and competing priorities
• Strong customer service-oriented focus
• Knowledge of relevant laws, regulatory and accreditation requirements, and standards
• Strong interpersonal skills, establishing rapport and working collaboratively with others
• Familiarity with managed care contracting; ability to interpret contract language and key provisions to ensure data received and maintained in source systems is in accordance with the scope and intent of the contract.

Preferred Education

• Bachelor of Arts or Science degree

Preferred Work Experience and Qualifications

• Seven (7) years of experience processing contracted provider demographic data within a managed care organization applying knowledge and experience to ensure information is accurately captured and maintained to allow for critical downstream functions (claims processing, network adequacy reporting and directory processe
• Project management, business analysis, and process improvement experience in healthcare, managed care, or government programs industry
• High level of proficiency in Microsoft Office products and proficient in various software applications (e.g., SAS Software) with strong aptitude to perform complex data configuration tasks
• Understanding of managed care contracting and data management reporting requirements
• Advanced knowledge of relevant laws, regulatory and accreditation requirements, and standards
• Ability to synthesize a variety of data to produce a cohesive and well-documented process
• Ability to work with a diverse group of people both internally and externally, including physicians, management, and leadership; ability to develop strong interpersonal relationships and use tact, diplomacy, and influence as necessary to achieve desired outcomes.
• Experience working on a team or in cross-functional work groups

Equal opportunity employer

At Northwest Permanente, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants without regard to race, color, religion, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military and veteran status, and any other characteristic protected by applicable law. Northwest Permanente believes that equity, inclusion, and diversity among our employees are critical to our success, and we seek to recruit, develop, and retain the most talented people from a diverse candidate pool.