Lead Provider Data Quality Admin (Hybrid - Troy, MI) - Health Alliance Plan

GENERAL SUMMARY:

Responsible for ensuring compliance with job duties assigned as well as coordinating all internal focused provider data intelligence and analytics activities.

Produces reports related to the development of new concepts, ideas, products and services for Provider Network and Product Development initiatives. Provides compliant consistent and highly sophisticated analytical support for all initiatives in support of the Product Network Management and Product Development departments.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Leads all Provider Data Quality compliance initiatives and ongoing maintenance projects.
• Ensures all Provider Network Management policies, procedures, and processes conform to current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
• Ensures staff members are educated in departmental policies and procedures.
• Executes analysis and thoroughly understands the product portfolio. Supports the creation of recommendations and the availability and accessibility of internal provider network intelligence.
• Provides qualitative and quantitative research used to evaluate market conditions and new product initiatives. Assists the manager with the optimization of the product portfolio for meeting market needs, gaining competitive advantage, accounting for political, economic, social, and technological environment. Simultaneously managing return on investment and monitor performance.
• Leads and coordinates Provider Network and Product Management initiatives guiding multiple resources to design and execute reports which draw upon multiple data sources, identify growth opportunities, competitor offerings and product performance.
• Communicates with stakeholders' insights, conclusions, and recommendations drawn from analysis in both written report and verbal presentation form, to direct business decision making.
• Identifies potential product adjustments, additions and deletions based on provider network intelligence and supports the product management lifecycle through analyzing product membership and performance.
• Administers provider network forecasts as well as forecasts for planning activities including membership growth and retention as it relates to the provider network, in both new areas for expansion and current service area.
• Develops and maintains reporting databases required by various functions in the organization such as Provider Network, Sales, Product Management and Marketing. Leads data analysis and provides support, including ability to design, develop, and navigate company databases and support systems, in accomplishing initiatives and business activities across the enterprise. This includes, but is not limited to access standards for CMS, NCQA, ACA and DIFS.
• Leads initiatives related to network adequacy and disruption reporting for current service area(s) and supplies intelligence for potential service area expansion opportunities.
• Gathers, compiles, analyzes, and interprets internal information to support all supported business functions using MS Access, Geo Mapping and Network Adequacy software, HAP databases and other sources, while designing and generating ad hoc and standardized reports. Fulfills work requests and complete deliverables in a timely manner while providing excellent customer service. Works collaboratively with team members.
• Participates in developing marketing plans, business plans and new marketing materials and support work groups as requested.
• Ensures HAP has signed delegation agreements that are in compliance with current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
• Advises leadership of any substantial change in standards that may require the installation of new procedures/staff training.
• Perform other duties as assigned.

EDUCATION/EXPERIENCE REQUIRED:

• Bachelor's degree in business or related field. An additional four (4) years of related experience may be considered in lieu of degree.
• Minimum of three (3) years of experience in data analysis required.
• Minimum of four (4) years of experience in the health insurance industry required.
• Knowledge of network adequacy - CMS, DIFS, MDHHS, HSAG.
• Experience with the regulators to assist with audits.
• Experience with statistical analysis and relational databases.
• Experience with database reporting tools required.
• Proficiency in MS Office, specifically Excel and Access required.
• Health Plan functional knowledge required.
• Experience with presentations and public speaking desirable.
• Project Management skills including the ability to coordinate activities among various departments and work independently to meet timelines.
• Excellent written, oral, and interpersonal skills.
• Work with all levels of diverse people.
• Ability to adapt to changing situations and manage multiple projects simultaneously.
• Self-motivated and able to work independently.
• Accountability to complete all initiatives with accuracy, a focus on meeting timelines and exceeding customer expectations.
• Knowledge of managed care concepts and healthcare industry required.
• Knowledge of provider network compliance requirements.
• Knowledge of standard metrics used in the managed care industry required.
• Understanding of available data sources for competitive intelligence gathering.
• Advanced analytical and problem-solving ability required.
• Familiarity with basic project management techniques preferred.
• Financial or product management background.
• Willing to work extended hours based on department's priorities.
• Experience interpreting, altering, and executing SQL.

• Organization: HAP (Health Alliance Plan)
• Department: Provider Network Operations
• Shift: Day Job
• Union Code: Not Applicable