Provider Data Representative
About The Position
The Provider Data Representative maintains accurate provider demographic, participation, credentialing, enrollment, roster, and directory information across all systems supporting the World Trade Center Health Program (WTCHP). The role ensures provider data integrity to support accurate claims payment, credentialing compliance, provider directory accuracy, and network participation. The Representative partners with Provider Relations, Credentialing, Provider Data, Claims Operations, and Contracting to keep provider information complete, accurate, timely, and compliant with organizational standards.
Requirements
- 3 + years of related experience
- Data Integrity
- Data Quality
- Document Revision
- Operations Processes
- MBI (T2) clearance
Nice To Haves
- US Citizenship
Responsibilities
- Process provider roster submissions and updates.
- Maintain accurate provider demographic, enrollment, and participation records.
- Validate and update NPIs, TINs, specialties, practice locations, EFT details, and affiliations.
- Ensure timely changes supporting accurate claims payment and directory publication.
- Reconcile provider rosters against credentialing, claims, enrollment, and directory systems.
- Identify discrepancies impacting participation, claims payment, or directory accuracy.
- Coordinate corrections with Provider Relations, Credentialing, and Provider Data teams.
- Validate provider demographic information for credentialing/recredentialing.
- Identify and resolve enrollment and participation discrepancies.
- Ensure data requirements are complete for onboarding and participation activation.
- Audit provider records for completeness, accuracy, and compliance.
- Monitor directory accuracy, quality scores, and claims‑impacting error rates.
- Support development of data standards, QA programs, and process improvements.
- Identify provider data issues affecting claims adjudication, reimbursement, and participation.
- Collaborate with Claims Operations to resolve data discrepancies; support root‑cause analysis and remediation.
- Produce provider data quality reports, discrepancy logs, and audit results.
- Track maintenance productivity, turnaround times, and accuracy metrics.
- Provide insights to leadership to guide operational improvements.
- Communicate data requirements and discrepancies to credentialing, enrollment, and provider relations teams.
- Provide clear documentation for provider updates and requests.
- Recommend system enhancements, automation opportunities, and updated workflows.
- Support implementation of new processes, templates, and operational tools.
Benefits
- Medical plan options
- Health Savings Accounts
- Dental plan options
- Vision plan
- 401(k) plan with company match
- Flexible work weeks
- Paid time off (vacation, sick, personal)
- Paid holidays
- Paid parental leave
- Paid military leave
- Paid bereavement leave
- Paid jury duty leave
- Short-term disability benefits
- Long-term disability benefits
- Life insurance
- Accidental death and dismemberment insurance
- Personal accident insurance
- Critical illness insurance
- Business travel and accident insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
