Provider Network Data Specialist

The Provider Network Data Specialist ensures the accuracy, completeness, and integrity of provider data in the provider management database and across all systems and resources. This role also ensures integrity of provider data received from first-tier, downstream, and related entities. Through effective data management, reporting, and analysis, this position supports network adequacy, provider accessibility, and quality performance. This position plays a critical role in maintaining compliance with network standards and regulatory requirements. By delivering reliable provider information, this position helps ensure member access to care and supports provider satisfaction. 

 

1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. Manages provider data in the provider management database and serves as the subject matter expert on platform functionality. Supports data reporting, team workflow, and operational efficiency, recommending process improvements when appropriate to ensure consistency and accuracy across outputs.

 

3. Ensures provider data in the provider management database is accurate, complete, and updated timely and in accordance with contracting and credentialing policies and processes.

 

4. Acts as a data liaison between Provider Relations and the Data Infrastructure team; facilitates the integration of partner-provided data, leverages external provider data sources, and ensures optimal use of provider data systems and software solutions. 

 

5. Supports internal and external provider network audits and reports related to National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Michigan Department of Health and Human Services (MDHHS). 

 

6. Responsible for the development, maintenance, accuracy, and oversight of print and web-based provider directories and search tools for all product lines; coordinates regular reviews and member usability testing to meet accessibility and understandability standards. 

 

7. Develops and maintains reports to monitor provider network adequacy, completeness, demographic accuracy, access and availability, and participation trends; conducts outreach and completes exception requests as needed to support network compliance and performance.  

 

8. Facilitates provider satisfaction surveys to meet NCQA and contractual requirements and supports initiatives to maintain or improve provider satisfaction. 

 

9. Supports quality management and company-wide quality initiatives such as Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Health Plans (CAHPS), and NCQA.

 

10. Supports processes to ensure access and availability of providers, including, but not limited to, secret shopper surveys, after-hour surveys, and any additional initiatives, outreach, and follow-up as appropriate. 

 

11. Supports compliance processes, including, but not limited to, provider site visits and documenting compliance actions and findings in the provider management database. 

 

12. Supports network rental relationships by ensuring commercial carrier reporting is efficient, accurate and up to date. 

 

13. Maintains confidentiality of client data.

 

14. Performs other related duties as assigned or requested.

 

Bachelor’s degree in health information management, healthcare administration, public health, 

business analytics, data science, or related field. 

 

Bachelor’s degree in health information management, healthcare administration, public health, 

business analytics, data science, or a related field, supplemented by formal training or 

certifications in healthcare data analytics or provider network management. 

 

Two (2) years of experience in provider data management, provider relations, health analytics, health information systems, healthcare operations, or related. 

Three (3) to five (5) years of progressive experience in provider data management, provider relations, or health analytics. Demonstrated experience in developing reports, analyzing healthcare data, and supporting regulatory audits or quality initiatives.

 

Proficient in Microsoft Office (Word, Excel, and Outlook) 

Attention to detail and analytical skills

Excellent human relation and oral/written communication

Excellent organizational and prioritization abilities

 

Familiarity with CMS, NCQA, and MDHHS network adequacy standards

Understanding of healthcare provider networks and regulatory requirements

Experience developing and interpreting reports for performance monitoring and compliance 

Ability to identify process improvement opportunities and implement solutions

Experience with provider management systems or health plan software (e.g., credentialing databases, provider directories) 

Proficient in MS PowerPoint

 

 

[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:

 

Ability to access departmental files

Ability to enter and access information from a computer

Ability to access all areas of the UPHP offices

Occasionally lifts supplies/equipment

Prolonged periods of sitting

Manual dexterity 

 

Works in office conditions, but occasional travel may be required

Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration

Subject to many interruptions

Occasionally subjected to irregular hours