Provider Data Integrity Specialist

The Provider Data Integrity Specialist maintains the integrity of all demographic and reimbursement information for the companys provider network, ensuring that all processes and procedures are completed in accordance with established state and federal laws and regulations, company policies and procedures and contracted terms.

Duties and Responsibilities

• Responsible for accurate and time maintenance of provider configuration in accordance with state and federal laws and regulations.
• Serves as the subject matter expert regarding provider configuration in the claims processing system(s) and its impact to claims processing and provider reimbursement.
• Monitor proposed/approved changes to state and federal law, assess the impact on provider configuration and institute changes as required to remain compliant with regulations governing the company.
• Assist in the timely maintenance of the Provider Directory; the Provider Manual; the provider pages on the company website and the provider communication network software in accordance with state and federal laws and regulations.
• Work cross-organizationally (e.g. Credentialing department, Claims department, etc.) to ensure identified issues that affect provider claims processing and provider reimbursement are corrected in an accurate and timely manner.
• Responsible to extract, review and provide quality control on provider configuration to ensure consistency in all applicable software.
• Manage and respond to all provider credentialing request.
• Ensures all provider with our vendors is monitored and kept current. Performs thorough quality review of all completed provider data updates.
• Creates and maintains all Provider Data Integrity desktop procedures.
• Claim processing oversight and impact analysis on all adjustments made due to an update in provider data.
• Responsible to identify internal and external opportunities for provider education.
• Responsible to identify and, as approved, implement opportunities for process improvement both internally and externally.
• Works on special projects as assigned by Manager
• Performs other duties as assigned by Manager
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

• Bachelors degree or Associates degree or a minimum four (4) years experience in health insurance or health care operations or related field in lieu of a degree
• Minimum of three (3) years data entry experience
• Extensive knowledge of health insurance, insurance laws and regulations, claims processing, medical and insurance terminology and procedure and diagnostic codes
• Knowledgeable of provider, facility and reimbursement mechanisms
• Proven ability to work cross-organizationally to achieve the goals of the organization and department
• Knowledge of the provider credentialing and contracting process as it relates provider affiliations and reimbursement
• Knowledge of cross-functional software module; Electronic Data Interchange (EDI) claim submission, provider remittance advice and provider timely filing protocols
• Proven ability to analyze problems, draw relevant conclusions and work with all levels of staff to implement appropriate change
• Strong oral and written communication skills and the ability to understand and interpret complex and/ or technical information
• Strong data analysis skills
• Strong Microsoft Excel skills

Preferred:

• Bachelors degree
• Detailed knowledge of government healthcare program regulations
• Experience working with Cognos
• Knowledge of Microsoft SharePoint

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.