Temporary Operations Resolution Specialist – Provider Data Management

• Manage the integrity of the Health Plan's provider data to maintain compliance with Federal and local requirements
• Serve as department subject matter expert on plan systems, tools, policies, and procedures
• Act as liaison with internal and external customers
• Conduct audits to ensure compliance with Centers for Medicare and Medicaid Services (CMS) requirements
• Produce accurate provider data reports required by CMS for HEDIS purposes
• Identify root causes of provider data discrepancies
• Work alongside Operations Resolution Specialists across the plan to resolve issues
• Prepare initial direct and delegated credentialing rosters for the automated Provider Data Load (PDL) process
• Process PDL rejection reports and correct discovered errors
• Educate CINs and groups on direct and delegated roster formats for future expansion and accurate PDL
• Perform internal monitoring audits of provider data, including demographic changes, TIN additions, and provider terminations

• Associate or Bachelor's degree preferred
• One to three years experience preferred in either managed care health insurance
• Effective communication skills
• Strong written and verbal communication skills
• Analytical and problem-solving skills
• Experience using computer systems and office automation applications
• Knowledge of provider credentialing and contracting terminology
• Basic knowledge of healthcare claims process
• Knowledge and competence in regulatory requirements for Health Plan provider data
• Ability to maintain confidentiality and use discretionary discernment with sensitive materials

Demonstrates expertise in managing provider data integrity and compliance with Federal and local requirements, including knowledge of CMS regulations and provider credentialing processes. Strong analytical, communication, and problem-solving skills are essential for effective collaboration and issue resolution.