Job Abstract

The Provider Network Data Associate II is in support of the LA Care Health Plan's Medi-Cal, Healthy Families Program, Healthy Kids, Direct Medi-Cal, Special Needs Plan (SNP) and Duals Pilot Product Lines with sole responsibility for monitoring and evaluating the movement of providers across all Plan Partners and Participating Physician Groups (PPG's).  Principle duties include maintaining an up to date Provider Database ensuring integrity in order to generate accurate Provider Directories for LA Care Health Plan's various product lines; working in conjunction with Member Services to effectively coordinate member re-assignment upon termination of a Primary Care Provider (PCP); providing assistance to the Claims Department to ensure timely processing of claims payment; and entering new contract into the Manage Health Care (MHC) System and making modifications to existing contracts. The position is responsible for assisting in the collection, analysis and evaluation of data in order to conduct complex studies through the use of statistical tools (e.g. chart, data graphs, and trend analysis) to prepare reports with graphic illustrations that draw conclusions based on findings. Other duties include generating required reports to be submitted to the Department of Managed Care (DMC), Managed Risk Medical Insuarence Board (MRMIB) and Geo Access.  

Provide support to the Provider Relations Department. Support of the L.A. Care Health Plan's Medi-Cal, Healthy Families Program, Healthy Kids, Direct Medi-Cal, SNP and Duals Pilot Product Lines with sole responsibility for monitoring and evaluating the movement of providers across all Plan Partners and Participating Physician Groups (PPG's). Assist in generating/compiling the Provider Network Capacity Report, Quarterly Impact Report to the State and Chief Executive Officer (CEO) Monthly Performance Report for monitoring the physician network. (25%)

Assist Member Services to solve provider discrepancies.  Works closely with Member Services to effectively coordinate member re-assignment upon termination of a Primary Care Provider (PCP). (20%)

Coordinate the entry of provider contracts into the MHC and MPD Database.  Ensure that provider contracts are properly entered into the MHC an MPD database.  Maintaining an up to date Provider Database.  Ensure integrity in generating accurate Provider Directories for LA Care Health Plan's various product lines.   working in conjunction with Member Services to effectively coordinate member re-assignment upon termination of a Primary Care Provider (PCP). (20%)

Participate in Healthcare Effectiveness Data and Information Set (HEDIS) reporting efforts. (5%)

Ensure that all PPGs receive their Eligibility list within 5 days. (20%)

Perform other duties as assigned. (10%)

At least to 0-6 year of healthcare work related Care experience, understanding of provider data requirements and claims processing.

Required:
Access, Excel, Word proficiency.

Strong analytical skills.