Provider Data Specialist_NO

Versant Health•Troy, NY

About The Position

The Provider Data Specialist role is responsible for educating, verifying, monitoring, and accurately managing all of Versant Health’s two national networks of 80,000+ Ophthalmology and Optometric practitioner’s and office’s demographic and payee data. The role performs additions, changes, and terminations to Versant Health’s provider data systems to positively effect the accuracy of the Provider Directory, Utilization Management and authorizations, and claims processing. The Provider Data Specialist role will also perform periodic audits, maintenance, and troubleshooting of provider, office, and payee data utilizing the National Practitioner Identifier (NPI) Registry, state’s Provider Master Files for Medicaid Registration, and Tax Identification programs.

Requirements

Four to Five (4-5) years of experience with a managed care organization in a Provider Data Mangement, Credentialing, Nework Management, Network Deveopment, and/or Provider Relations role
Capable and comfortable dealing with Protected Health Information (PHI), Personal Identifiable Information (PII), sensitive, and confidential information with discretion and trust
Experience must include direct responsibility for managing provider, office and payee data and/or claims processing.
Experience working with provider networks and healthcare providers.
Knowledge and experience in CMS Provider Directory regulations
Proficiency in MicroSoft Office Excel, Word, Excel, Access, and Power Point
All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Nice To Haves

Associate or Bachelor’s degree preferred

Responsibilities

Directly responsible for creating newly contracted providers, their offices, and payee(s), into the three (3) provider databases based on data received via contracting, credentialing reports, and direct provider submissions
Directly responsible for creating new non-contracted providers, their offices, and payee(s), into the three (3) provider databases; comprehensively reviews and edits existing non-contracted provider data to facilitate accurate claims processing and the issuance of authorizations.
Directly responsible to comprehensively reviewing, editing, updating existing provider, office, and payee records as needed and as requested. Requires review of documentation and reports, as well as acting on requests from internal and external customers.
Directly responsible to terminate provider, office, and payee records as requested using correct termination reason codes to determine controllable and noncontrollable terminations. Requires extensive review of documentation and reports, as well as acting on requests from internal and external customers.
Manage complex Retailer and Provider Group data by periodically receiving and comprehensively reviewing the provider databases and rosters and performing updates to the three (3) provider databases.
Directly responsible for managing “Provider Pick” and “Provider Contract” claims pend queue and providing guidance to Claims on claims processing.
Maintain IRS standards for Payees and utilize Tax Identification Number verifications.
Annually, resolve all 1099-B submissions to Versant Health
Support Versant Health Accounts Receivable Department with provider education on Negative Balance accounts and network suspension and reactivations
Educate and assist Providers and their office personnel with understanding the uses, importance, and impact of their provider data to Members and the Provider Directory
Educate and assist all Versant Health departments with provider data, Provider Directory questions, and various data integrity projects.
Review and process Provider Directory data updates received from contracted Provider Directory & Outreach vendors to ensure data accuracy; perform updates, corrections, and terminations of provider and office data.
Initiate and/or support provider database improvements and communication processes as needed with other departments regarding database enhancements.
Contact assigned providers to validate required data elements via phone and/or email.
Conduct peer review audits and provide feedback to reduce errors and improve processes and performance, maintaining current provider data to ensure the quality of the network, and may be responsible for representing the provider network area on department related IT projects.