Provider Data Resolution Spec

Profile

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, , IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Ensures accurate, timely maintenance, and synchronization of critical Provider data on all Provider databases, and systems such as Claims, Data Management, and Authorization/Referral systems. Accesses and utilizes multiple software applications. Applies business rules and knowledge of Provider contract language, pricing and reimbursement methodologies to each database/system to validate Provider information in all systems. Communicates with internal and external customers by phone and email to clarify data and follow-up on issues, working under timeline, accuracy and production targets.

Requires the ability to manage a large amount of complex information, communicate clearly, and draw sound conclusions. Performs simple credentialing activities including performing primary source verifications and entering the initial data of potential Providers into the Provider database and credentialing system(s). Collaborates with the Provider Data Specialists and provides clear instructions to correct data issues. Ensures correct reimbursement and Provider data is housed in all downstream systems.

• High School Diploma or GED
• If supporting TRICARE contract, must be a U.S. Citizen
• If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DOD) background adjudication
• 2 years of varied responsible experience with computer database programs
• 2 years of Health Care experience such as claims, provider data or authorization or referral processing
• Experience with Microsoft Suite (including, but not limited to, Word, Excel and Outlook)

• 1+ years of Health care claims resolution experience
• Experience using a Provider Data Management System, Claims System, or Authorization/Referral system

• Resolves Provider data discrepancies related to claims processing, including contract reimbursement rates within the allotted timeframe.
• Manages daily follow up of Provider data correction requests and issues to ensure databases are current and accurate.
• Ensures and maintains accurate data within the Provider Claims and Authorization databases.
• Contacts providers to verify all credentialing, claims, and billing information.
• Ensures appropriate tax documentation is obtained and imaged for Provider files.
• Corrects reimbursement issues within claims payment system.
• Develops, maintains, and processes reimbursement terms ensuring correct claims payment and downstream processing.
• Reviews Provider contract language and identifies when a contract is out of compliance. Processes Provider contracts, run reports, and responds to inquiries regarding contract compliance issues; images and indexes contracts and return images to network subcontractors; conducts quality assurance activities to ensure image quality and completion of image activities. Queries primary sources and OIG, as applicable, to verify Provider credentials and qualifications.
• Professionally and concisely communicates in writing and by phone, information and/or instructions for updating and correcting databases.
• Resolves 1099 and W9 discrepancies.
• Assist in the development and update of protocols and procedures.
• Coordinates with Claims and other departments on Provider database related issues.
• Resolves daily error reports which include data rejected from claims system including data rejecting from all downstream systems.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

• Commitment to Task:
  Ability to conform to established policies and procedures; exhibit high motivation.
• Communication / People
  
  Skills:
  
  Ability to influence or persuade others under positive or negative circumstances; adapts to unique styles; listens critically; collaborates.
• Comp…