Provider Database Analyst

Salary Range: $83,243 - $124,864
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status: Exempt
Department: Provider Network Operations

Reports To: Manager, Provider Data, Credentialing and Reporting

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521.

The Provider Database Analyst is the subject matter expert in all SCFHP systems that support and rely on data related to the SCFHP provider network. The Provider Database Analyst uses analytical skills to independently interpret system functionality, reporting requirements and operational needs and evaluates and implements procedures to optimize systems for operational and reporting purposes in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and SCFHP business requirements to achieve Department performance objectives.

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Maintain a working knowledge of SCFHP provider network structure and contracting relationships and apply to day-to-day management of the information contained in the core operating/claims system.
2. Research and interpret applicable regulatory and industry guidelines in order to guide decision making.
3. Work collaboratively with Information Technology (IT) to communicate systems regulatory and reporting requirements related to the Provider Network Management department. Act as subject matter expert regarding integration between systems utilizing provider data, including any activities related to data maintenance, system conversions and upgrades requiring validation and testing.
4. Maintain a current understanding of all operational data processes (provider directories, website, portals, QI initiatives, access studies, HSD tables, contracting and credentialing processes, UM and claims payment) with dependencies on provider data. Analyze systems, establish and document procedures to support operations.
5. Use knowledge regarding operational and regulatory requirements to guide efforts to produce accurate, complete, and dependable data and reports required for business and regulatory purposes.
6. Produce provider lists used to create all variations of print provider directories.
7. Document policies, procedures, workflows and work instructions related to departmental systems and data. Preserve revised and retired versions and maintain documents in accordance with company policies. . Train SCFHP staff on policies, procedures, workflows and work instructions to ensure compliance.
8. Cross-train on and provide back-up support, when necessary, to enter information into other provider data management systems that are the systems of record for provider demographic, credentialing and contract data to support information entered in core operating/claims system.
9. Oversee all data entry activities in core systems and utilize SQL validation reports to ensure accuracy and reconcile discrepancies between systems.
10. Serve as primary contact person for day-to-day interactions with software vendors for products primarily utilized by Provider Network Management.
11. Use analytic skills to review data to guide decision making around contracting strategies.
12. Perform other related duties as required or assigned

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Bachelor's Degree in Computer Science, Business, Health Administration or a related field, or equivalent experience, training or coursework.(R)
2. Minimum three years of experience in a managed care environment with an emphasis in provider database management, healthcare analytics, claims pricing, auditing or configuration. (R)
3. Experience with MS SQL Business Intelligence tools for the purpose of database reporting and configuration. (R)
4. Experience with database concepts and data processes in order to understand, develop, analyze the systems and data that support SCFHP's provider network; make recommendations for improvements to existing processes. (R)
5. Knowledge of CPT, HCPC, Revenue and ICD codes used for medical claims billing. (R)
6. Knowledge of provider contracts, fee schedules, and reimbursement methodologies, including Medi-Cal, Medicaid and/or Medicare guidelines. (R)
7. Project management skills to support simultaneous projects and initiatives. (R)
8. Strong problem solving skills; ability to think creatively and logically in a fast-paced environment. (R)
9. Proficient at adapting to changing situations and efficiently alternating focus between tasks to support department operations as dictated by business needs. (R)
10. Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, Excel and PowerPoint. (R)
11. Ability to use keyboard with moderate speed and high level of accuracy. (R)
12. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
13. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
14. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
15. Ability to maintain confidentiality. (R)
16. Ability to comply with all SCFHP policies and procedures. (R)
17. Ability to perform the job safely with respect to others, to property and to individual safety. (R)

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

General office conditions. May be exposed to moderate noise levels.

EOE