Responsible for accurate and timely configuration of contracted and non-contracted provider data. This includes but is not limited to demographics, network participation, provider types/specialties, vendor billing information and contracts for non-contracted vendors. Responsible for timely management of pended claims where a provider and/or vendor were unable to be assigned by the software system. Timeliness is critical due to interest expense, provider and/or client performance guarantees.The position utilizes configuration utilities/tools that update large amounts of data such as network imports. Analysts correspond with provider offices and external vendors, e.g., claim clearinghouses, data validation vendors, etc. They also support internal customers regarding provider system capabilities and/or issues.
None specified CERTIFICATION & LICENSURE REQUIREMENTS
None specified EXPERIENCE REQUIREMENTS
Two years of experience in managed care, health care and/or health insurance operations. SKILLS AND KNOWLEDGE
Understanding of medical and/or dental claim billing practices. Computer proficiency in PC applications (Word, Excel). Good decision-making based on various data points to ensure accurate provider and vendor assignment.
- Responsible for accurate and timely configuration and maintenance of provider and vendor data including demographics, network participation, provider directory data, provider types/specialties, vendor billing information and contracts for non-contracted vendors. This includes code and support file management and other reference data tables.
- Responsible for timely management of pended claims where a provider and/or vendor were unable to be assigned by the software system. Timeliness is critical due to interest expense, provider and/or client performance guarantees.
- Responsible for adding roviders to Prior Authorization records with a missing provider ID.
- Responsible for utilizing configuration utilities/tool sets to update large amounts of data such as provider network tables. Review of data is required in Proof of Concept environment prior to promoting to Production environment.
- Provides support to provider offices and external vendors including but not limited to claims clearinghouses, provider data management solution as well as providing support to internal customers.
- Responsible for development and execution of test plans for system capability and/or enhancements related to provider and vendor data configuration.
- Collaborate with Provider Network Management Department on process improvement activities to faciliate communication and coordination of provider update requests.
- Works closely with claims leadership to ensure highest level of automation where provider demographics, networks and other elements are impactful to accurate and efficient claims processing.