Provider Data Management Specialist

Health New England

Springfield, MA, USA

Published: 6/14/2022

Education

Full Time

Job Description

SUMMARY: The Provider Data Management Specialist is responsible for installation and ongoing maintenance of provider data systems at Health New England. Validate the integrity of provider information for the purposes of enrollment, claims processing, PCP selection, as well as provider directories and online search results to ensure provider and member satisfaction. Serve as a liaison for vendors, Physician Hospital Organizations (PHOs), and large groups for the purposes of receiving, evaluating and loading provider data in both the web-portal and Amisys batch load process. Identify system configuration needs, including Reference and Controls, Provider, and Correspondence Generator. Audit provider data, reports and directories to ensure accuracy and compliance with regulatory requirements and accreditation standards, including but not limited to Division of Insurance (DOI), Centers for Medicare & Medicaid Services (CMS), Healthcare Effectiveness Data and Information Set (HEDIS), Health Insurance Portability and Accountability Act (HIPAA) and National Committee for Quality Assurance (NCQA). Support the secure online provider portal and confirm and maintain users to ensure appropriate access for users to confidential data and Protected Health Information (PHI). These functions directly impact the experience of the members, providers, and third-party administrators that access contracted providers and utilize provider look-up data.

ESSENTIAL FUNCTIONS:

Configure and manage provider data in the Amisys database - 50%

Researches and analyzes provider payment policies
Configures and maintains provider affiliation templates for entry automation
Configures web-portal to support new Integrated Delivery Network (IDN) and large group contracts, provider payment arrangements and provider publication using the Requested Data Elements (RDE) Spreadsheet and Amisys batch load processes.
Monitors and updates data based on revised rosters received from health systems and other contracted providers in a timely manner.
Ensures organized storage of all relevant provider documents.
Investigate and resolves provider file inaccuracies and discrepancies, coordinating with other departments as necessary.
Interacts with provider offices and internal departments to verify updates to provider information.
Assists with provider education efforts for contracted status inquiries.
Coordinates with Credentialing department to identify and update provider data based on provider credentialing efforts.
Processes provider configuration, change, and inquiry requests submitted through various sources, such as telephone, fax, mail, and email. Researches, resolves and routes requests to other departments as appropriate.
Configures and processes electronic provider enrollment of vendors, PHOs and large groups.
Creates and maintains providers, provider groups and offices for payment purposes.
Identifies and coordinates the entry of Specialty Code, Office Hour and Panel Status code sets.
Develops and maintains provider and affiliation records for each carrier based on payment, Tiered Provider Network designation, and network participation.
Configures Amisys CG letters according to departmental and regulatory specifications.
Communicates directly and works collaboratively with the providers, office staff, participating PHOs, Independent Practice Organizations (IPAs), and vendors to ensure proper setup of providers.
Collaborates with Contracting, Credentialing, and Configuration to ensure accurate entry of providers.
Partners with the Claims Department to ensure accurate setup and payment of claims.
Processes and maintains Electronic Remittance Advise (ERA) requests received from providers, vendors and clearinghouse partners.
Reviews, prepares, and enters non-plan providers using the weekly reporting of claim Explanation Codes of 10 (EX10) and 11 (EX11) Pend codes, while consistently evaluating process to incorporate enhancements, automation and other system improvements.
Communicates with Claims Department and other internal departments as appropriate via e-mail, paper claim, or EX11 regarding the status of Out-of-Plan (OOP) providers.
Ensures adequate phone coverage for department during business hours.

Department and Secure Web Portal Access Support and Project Management - 25%

Identifies opportunities for improving interdepartmental and operational issues.
Processes provider configuration, change, and inquiry requests submitted through various sources, such as telephone, fax, mail, and email. Researches, resolves and routes requests to other departments as appropriate.
Educates and collaborates with vendors, PHOs and large groups, Credentialing, Contracting, and IT departments for the purposes of electronic file feed completion, submission and validation based on contract submission.
Updates provider data received from vendors, PHOs and large groups, as a result of provider audit requests, contract configuration and risk pool assignment.
Conducts investigation of medical claims submitted by providers, vendors, and internal HNE customers (Claims, Member Services, Provider Relations, Complaints & Appeals, etc.) by researching provider configuration for appropriate resolution and processing.
Processes and triages Electronic Funds Transfer (EFT) requests received from providers, vendors and clearinghouse partners through collaboration with the Accounting department.
Generates reports (claims, member panel, region, etc.) for Provider Configuration, as well as other internal and external customers when appropriate, using the DataMart and other network resources.
Establishes effective working relationships with internal departments to request and provide information to resolve outstanding provider issues.
Analyzes and updates provider Tax ID data to be used to generate 1099 coupons to vendors and providers.Maintain accurate provider data and documentation, which includes evaluating provider setup, assuring identification of potential problems and reviewing provider data for potential errors.
Manages, triages, and participates in the resolution of issues received through the Secure Web Portal mailbox, faxes, and phone calls.
Provides support and assistance to internal and external associates regarding the appropriate setup for providers in the web-portal.
Identifies data integrity issues and works closely with the IT Applications Department regarding issue resolution.

Provider Directory Management - 25%

Configures and maintains provider data in the HNE Provider Directory Extract (DDDI0C9) processes.
Conducts ongoing outreach to providers to validate provider directory data in accordance to CMS, DOI and NCQA regulatory requirements.
Conducts audits of provider directory data to ensure consistency within groups and specialties.
Validation of HNE provider directory, and online provider search results.
Creation and ongoing management of employer group and / or line of business specific provider directories

MINIMUM REQUIREMENTS:

Associates degree and more than four years’ experience in data maintenance within a relational database system within a provider office environment, healthcare insurance, or healthcare vendor organization, or an equivalent combination of education and experience.

Previous health insurance / network experience preferred
Amisys experience preferred, but not required
Ability to adapt to a fast paced, continually changing business and work environment while managing multiple priorities
Excellent follow-through skills, self-motivated and detail-oriented
Strong organizational skills to manage multiple projects, issues, and priorities effectively and simultaneously, with attention to detail
Strong problem resolution skills
Well-developed organizational and prioritization skills
Skilled with Microsoft Office Suite
Excellent customer service, verbal and written communication skills

WORKING CONDITIONS: Works in a standard office-based environment