Provider Data Resolution Specialist

Provider Data Resolution Specialist

Join to apply for the Provider Data Resolution Specialist role at Tri West Healthcare Alliance
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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.

Department of Defense contract requires U.S. citizenship and a favorably adjudicated DOD background investigation for this position.

Veteran, Military Spouse or Military Affiliated applicants 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
• U.S. citizenship (if supporting TRICARE contract)
• Favorable interim and adjudicated final Department of Defense (DOD) background adjudication (if supporting TRICARE contract)
• 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 (Word, Excel, Outlook)

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

• Resolve Provider data discrepancies related to claims processing, including contract reimbursement rates within the allotted timeframe.
• Manage daily follow up of Provider data correction requests and issues to ensure databases are current and accurate.
• Ensure and maintain accurate data within the Provider Claims and Authorization databases.
• Contact providers to verify all credentialing, claims, and billing information.
• Ensure appropriate tax documentation is obtained and imaged for Provider files.
• Correct reimbursement issues within claims payment system.
• Develop, maintain, and process reimbursement terms ensuring correct claims payment and downstream processing.
• Review Provider contract language and identify non‑compliance; process contracts, run reports, and respond to inquiries regarding contract compliance; image and index contracts and return images to network subcontractors; conduct quality assurance activities to ensure image quality and completion of image activities.
• Query primary sources and OIG, as applicable, to verify Provider credentials and qualifications.
• Professionally and concisely communicate in writing and by phone, information and/or instructions for updating and correcting databases.
• Resolve 1099 and W9 discrepancies.
• Assist in the development and update of protocols and procedures.
• Coordinate with Claims and other departments on Provider database related issues.
• Resolve daily error reports which include data rejected from claims system including data rejecting from all downstream systems.
• Perform 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; adapt to unique styles; listen critically; collaborate.

Computer Literacy: Abil…