Job Details

POSITION SUMMARY

Provides advanced analytical techniques to ensure accurate contract information is applied for data entry into Symplr with correlation to QNXT system. Ensures company maintains high standards and compliance to regulatory requirements by maintaining effective multi-departmental improvement database, which integrates and coordinates results of all assessment/evaluation activities, problem identification and resolution activities. Responsible for accurate written and electronic provider directories. Responsible for providing support in the area of the Provider Directory compilation.

Responsible for reviewing, monitoring and auditing the departments daily Committee Finals.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including DHCS, DMHC, CMS and/or Medicare Part D and Special Needs Plan (SNP).

RESPONSIBILITIES

• Develops operations procedures by coordinating the gathering of provider information internally through contract development and claims submission, and externally through survey or by direct contact with network providers.
• Determines contracts to be assigned to providers by reviewing contract language.
• Maintains, produces and distributes network provider directories for all plan types by updating and maintaining provider site listings, creating database queries to produce accurate primary care site listings and hospital, specialty and ancillary referral panels.
• Informs all affected departments of updated information by meetings with or by routing notices through inter-company mail and e-mail to appropriate staff in Operations Claims, Health Care Services, Financial Services and Information Systems Divisions.
• Understand credentialing information (license types, provider types, & scope of practice) so data entry of QNXT will match provider’s credentials and scope of practice.
• Provides information as requested and contributes to the team effort by producing reports, labels and directories in a timely manner; maintaining established departmental policies and procedures, objectives, safety and environmental control standards; enhancing professional growth and development through participation in educational programs, current literature, in-service meetings and workshops; attending meetings as required and participating on committees as directed; working closely with Operations Claims and , Information Systems; and performing other related duties as assigned or requested.
• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks.
• Will need to provide backup support in the area of the Provider Directory compilation.
• This position requires occasional travel within the San Diego County area.