PCDM Data Analyst

Job Description

Job Description

POSITION SUMMARY :

The PCDM Data Analyst is responsible for Provider Credentialing and Data Management (PCDM) internal auditing processes, including delegates, partners-in-care (PICs), Credentialing Committee provider files, and various team workflows, provider files, reports, and other associated tasks and projects. The ultimate mission is to ensure accuracy in the credentialing database, Epic Tapestry, ProviderLenz, and other downstream systems to ensure adherence to state and federal requirements, NCQA accreditation standards, Medicare and Medicaid guidelines, and Community Care Plan (CCP) Credentialing policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES :

1. Gathers, interprets, and uses data to develop actionable steps that will improve Provider Data Management (PDM) and Credentialing processes and optimize results.

2. Analyzes provider records across multiple systems to ensure completeness and accuracy.

3. Conducts audits of provider files slated for Credentialing Committee review and AHCA PNV submission.

4. Coordinates, conducts, and documents audits as needed for investigative purposes, including Compliance and Special Investigations Unit requests.

5. Conducts periodic reviews of export files generated by the Credentialing System.

6. Responsible for assisting PCDM managers with audit requests and special projects.

7. Retrieves and compiles data across multiple information systems and provides needed information for internal and external customers in a timely manner.

8. Responsible for delegation auditing oversight for pre-delegates and annual reviews of existing delegates.

9. Completes and maintains detailed documentation of audits and findings identified in relation to Credentialing policies, training manuals, standard operating procedures, accreditation standards, Medicare and Medicaid guidelines, and state and federal requirements.

10. Analyzes provider data and identifies erroneous or questionable billing practices for CCP’s Council for Affordable Quality Healthcare (CAQH) Vendor Account.

11. Handles NCQA System Security Controls Audits to identify non-compliant modifications for corrective actions.

12. Prepares written summary reports of trending data related to audit findings in designated turn-around time.

13. Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.

14. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.

15. Interprets state and federal policies, Florida Medicaid, Children’s Health Insurance Program, and contract requirements.

16. Perform miscellaneous job-related duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

QUALIFICATIONS :

• Bachelor’s degree or equivalent experience (preferred).
• Proficient in SQL and data transfer between various sources (preferred).
• Knowledge of auditing, investigation, and research.
• Advanced in Microsoft Excel, Word, and PowerPoint.
• Minimum three (3) years of credentialing experience.
• Must have working knowledge of managed care or healthcare environment.
• Project management experience or certificate (preferred).
• Records and / or database management experience.
• Epic Tapestry system experience (preferred).

SKILLS AND ABILITIES :

Work Schedule :

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

PHYSICAL DEMANDS :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and / or move up to 15 pounds.

WORK ENVIRONMENT :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside / outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual

orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.