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Director Provider Data Management

3 months ago

Bathurst New Brunswick EB, Bathurst, Canada Community Health Plan of Washington Part time

This position is a Hybrid position with the option for either full-time in office or hybrid between remote/home and in office as required. It will require periodic meetings in the main office in Seattle. Any candidate located within Washington State is welcome to apply.

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

  • Strive to apply an equity lens to all our work.
  • Reduce health disparities.
  • Become an anti-racist organization.
  • Create an equitable work environment.

About the Role

The Director of Provider Data Management owns and is responsible for CHPW’s Provider Data Management Program, directing internal processes related to managing Provider Data Services; responsible for interpreting, analyzing, researching and maintaining accuracy and completeness of provider data across multiple databases and online provider directory. Oversight of the setup and maintenance of provider demographics, provider exclusions by regulatory authorities, provider terminations (voluntary and involuntary) in claims system and working directly with providers and internal departments to resolve escalated concerns.

To be successful in this role, you:

  • Have ten or more (10+) years’ experience within healthcare operations, operational quality improvement.
  • Have six or more (6+) years’ experience successfully managing and mentoring people leaders and direct reports required.
  • Have experience with contract negotiations and oversight of business process vendors.
  • Have five (5) years’ experience handling progressively more complex healthcare issues strongly required.
  • Have experience managing projects across departments and work groups.
  • Have experience with state and federal managed care preferred.
  • Have experience establishing and managing complex relationships strongly preferred.
  • Have experience with advanced analytic features of Access and Excel preferred.

Essential functions and Roles and Responsibilities:

  • Identify, lead, and contribute to short- and long-term organizational planning and strategy as a member of the leadership team. Represent provider data and Provider Data Services department on key cross-departmental and companywide projects, improvement teams, and organizational initiatives, CHPW’s Strategic Planning, and bringing on new products.
  • Responsible for directing PDS staff including identifying staffing and resource needs, build and manage highly effective teams with effective hiring, appropriate performance management to achieve department goals, staff development to achieve long-term operational excellence within Provider Data Services department.
  • Provide direction and manage key vendor relationships for provider data, configuration, enhancement development, quality assurance, and provider directory with NTT, Vision Services Plan and Washington Health Benefit Exchange (WAHBE), and others as needed. Partners with DHP/NTT for creation and administration of online provider data and provider and member portals (HealthMAPS, myCHPW).
  • Partner with Director, BPO to manage provider data maintenance vendor service level agreements.
  • Oversee budget requirements. Manage within approved budgets and request exceptions as needed.
  • Partners with Director, Business Process Operations (BPO) to direct prioritization of system configuration, testing and implementation activities involving provider data.
  • Create, maintain and project manage business/user requirements; user testing acceptance, peer review/approval, post-production monitoring and communication of provider data projects.
  • Establish standard process to monitor and report program performance, working across technical and departmental units to define business requirements necessary to support program performance measurement and evaluation activities.
  • Respond to State and Centers for Medicare and Medicaid Services (CMS) requirements for provider data quality assurance; TEAMonitor, Health Effectiveness Data and Information Set (HEDIS), National Committee for Quality Assurance (NCQA), all CMS audits (program audits, data validation, finance, and claims audits), and Washington state Office of the Insurance Commissioner (OIC).
  • Responsible for provider data results for annual Internal Claims audit, and annual delegation vendor audits, vendor quality monitoring, and Compliance audits.
  • Monitors and ensures compliance of departmental contractual compliance with Washington state, OIC and CMS requirements, including managing the collection and submission of required operational performance metrics and data reporting requirements. Point of contact for State, OIC, and CMS regulators for provider data.
  • Coordinate the priority of non-par claims management and provider data updates with vendors, ensuring the most effective outcomes for CHPW. Direct escalation of all non-par claims and provider data issues and facilitates resolution; communicates output to each CHPW business area.
  • Identify and execute process improvements to increase business process quality, and provider data accuracy and promote issue resolution.
  • Establish processes to effectively direct cross departmental workgroups, ensuring effective communication, issue resolution and decision making. Build credibility throughout the organization, ensuring Provider Data Services has appropriate relationships to achieve goals and objectives.
  • Provide back up and support to Directors of BPO, Claim Investigation Unit (CIU), Recovery, Coding team and Business Intelligence analyst for cost recovery and post payment review programs, vendor management, and CIU responsible for resolving provider claim processing concerns.
  • Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

  • Ability to coach, develop, motivate, and direct staff. Skilled in team building and effective management of cross functional relationships.
  • Working knowledge of health plan operations, managed care process, best practices, and operational interdependencies.
  • Analytical and organizational skills. Proven able to learn and understand information systems, in terms of business use and data architecture, as relates to program requirements.
  • Facilitation, negotiation, change management and conflict management skills.
  • Demonstrated project management and implementation management skills.
  • Knowledge of State and CMS requirements, policies, and data reporting requirements.
  • Excellent written and verbal communication and presentation skills, with the ability to communicate and work well with all levels of the organization and outside constituents.

As part of our hiring process, the following criteria must be met:

  • Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

  • Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
  • Vaccination requirement (CHPW offers a process for medical or religious exemptions).
  • Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime. Based on market data, this position grade is 71 and has a 15% annual incentive target based on company, department, and individual performance goals.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

  • Medical, Prescription, Dental, and Vision
  • Telehealth app
  • Flexible Spending Accounts, Health Savings Accounts
  • Basic Life AD&D, Short and Long-Term Disability
  • Voluntary Life, Critical Care, and Long-Term Care Insurance
  • 401(k) Retirement and generous employer match
  • Employee Assistance Program and Mental Fitness app
  • Financial Coaching, Identity Theft Protection
  • Time off including PTO accrual starting at 17 days per year.
  • 40 hours Community Service volunteer time
  • 10 standard holidays, 2 floating holidays
  • Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*:

  • Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

  • Extended periods of sitting, computer use, talking and possibly standing
  • Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
  • Frequent torso/back static position; occasional stooping, bending, and twisting.

Mental:

  • Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

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