Provider Data Quality Representative

Maintain provider data in the credentialing system, including adding new providers, updating existing providers and terminating providers when they leave the provider network.  Set up contracted rates to assure provider contract compliance.  Respond to requests from internal and external auditor regarding provider data accuracy and provider directory accuracy. 

Required:

1. Associates degree or high school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience with credentialing, claims, and provider data management.
2. Excellent communication and writing skills.
3. Experience in Microsoft Office (Excel, Word, Teams) and Adobe Acrobat with the ability to learn applications that support credentialing and provider data management processes.
4. General understanding of managed care plans and health insurance.
5. Critical thinking abilities along with the ability to work independently.
6. Proven time management and organizational skills.

Desired:

1. College degree preferred.
2. Experience with credentialing and provider data management system.

Responsibilities:

1. Maintain participating provider records in symplr Payer and the claims operating system with demographic, Tax ID, or other changes to ensure data accuracy.
2. Ensure newly contracted providers are accurately entered into symplr Payer.
3. Set up and maintain provider fee tables to ensure correct claims payment.
4. Enter credentialing applications to initiate the credentialing cycle.
5. Demonstrate compliance with NCQA NET 5, Element A-J and No Surprises Act to accurately populate provider directory information within the timely requirements.
6. Demonstrate compliance with NCQA NET 4, Elements A & B and state regulations to notify members of a provider termination within the timely requirements.
7. Manage returned mail, such as checks and EOPs, by researching and facilitating issue resolution,
8. Adhere to all The Health Plan (THP) policies and procedures, as well as, following regulations and standards established by NCQA, CMS, BMS, and the states where THP serves its members.
9. Research and resolve internal and external inquiries regarding provider status and system setup to ensure quality control.
10. Work collaboratively with the Provider Delivery Services team as well as all internal departments.
11. Assist with NCQA, CMS, BMS, state and internal audits.
12. Assist with training and development of employees related to provider data quality processes.
13. Maintain non-participating provider and dental records in the claims processing system with demographic, Tax ID, or other changes to ensure accuracy of information.
14. Create new non-participating provider and dental records in the claims processing system based on the information received on a claim.
15. Resolve data entry claims queue issues including data entry of non-participating providers.
16. Basic pay class assignment and maintenance to ensure the accuracy of claims payment.