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Manager of Provider Data Integrity

This position is responsible for the leadership and management of the Provider Data Integrity Team to execute deliverables. They play a critical role in executing and maintaining the quality of provider data; working directly with internal and external parties on all aspects of provider data. Identifies opportunities to continuously improve the data and provider onboarding processes, develop and lead strategy and road map for provider data integrity.
This role is responsible for provider data integrity activities related to requirements and business rules, analysis, quality assurance, continuous improvement of data collection, mapping, analysis and transformation of Provider Data Integrity. They will make recommendation to improve processes and systems to the leadership; and will relate procedures to IT systems, applications and business processes that are designed to enable the operations unit to accomplish its objectives.
In addition, this position has the primary responsibility to oversee the team to ensure staff is meeting both quality and production metrics, turnaround times for production standards should also be carefully monitored and reported. Acts as main contact for internal departments to support operational needs related to Provider Data Integrity and will understand the operations and technology in use by the business area to ensure that all resources are being used effectively. This role requires a leader with strong leadership, communication and analytical skills who is a subject matter expert for Provider Data.

Responsibilities include, but are not limited to the following:

  • Establishes/Maintains provider data integrity guidelines
  • Manages input provider data from various internal and external sources
  • Develops and implements strategies to simplify processes for team
  • Designs and develops workflows, protocols, and process models for use with Provider data management.
  • Apply industry-specific expertise to recommend and coordinate the development, enhancement and maintenance of a departments processes and procedures
  • Oversee process development and documentation for any new or altered functionality or business process. This will also include facilitating an annual audit of actual business processes verses what is documented
  • Contribute to development of business requirements, functional requirements, process flows, reference materials, user guides and code release artifacts as appropriate.
  • Serve as a subject matter expert for Provider Data
  • Respond to regulatory requirements impacting provider data including but not limited to key performance indicators.
  • Keep current with regulatory updates to ensure operational compliance for Provider Data management
  • Prioritizes data integrity business needs.
  • Resolves issues within internal departments related to interpretation of provider data management policies
  • Directs hiring and training of PDI Team
  • Ensures timely performance feedback and opportunities for staff development.
  • Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
  • Report to senior leadership project and work load allocation
  • Other duties as assigned

Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Job Qualifications

Required Qualifications:

  • Bachelors Degree preferably in Business Administration or Healthcare. Or must have sufficient amount of related work experience and background in lieu of a degree
  • Minimum of three (3) years of experience in health plan operations, specifically with provider data management, configuration and data loading procedures
  • Five (5) or more years with people management
  • Ability to think critically, drive change and influence individuals at all levels of the organization
  • Excellent written, oral communication and presentation skills
  • Strong Leadership and interpersonal skills

Preferred Qualifications:

  • Bachelors Degree in a related area
  • Three (3) years experience in healthcare setting, preferably with a background in provider relations, provider data management, or IS
  • Experience developing new business processes and procedures

Core Company-Wide Competencies:

  • Communicate Effectively
  • Respect Others & Value Diversity
  • Analyze Issues & Solve Problems
  • Drive for Customer Success
  • Manage Performance, Productivity & Results
  • Develop Flexibility & Achieve Change 

Job Specific Competencies:

  • Build Relationships & Cultivate Networks
  • Collaborate & Foster Teamwork
  • Attend to Detail & Improve Quality
  • Implement Strategy & Achieve Business and Financial Success

FDR Oversight:

In the role of business lead for assigned FDR, incumbent is responsible to complete comprehensive oversight and monitoring of their vendor that incorporates the following elements: efficient and effective operations; compliance with laws, regulations, policies, procedures; and other company performance issues designed to reduce risk and add value to the company.