Provider Data Specialist_NO

Versant Health•Troy, NY

23h•$20 - $23

About The Position

Versant Health is a leading administrator of managed vision care, serving millions of members nationwide. Our mission is to help members enjoy the wonders of sight through healthy eyes and vision. As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, including health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, and no-cost-to-you vision insurance for you and your qualified dependents. We are invested in your success with many opportunities for advancement and development. See how you can make a difference with the support of strong leadership and a team environment. See Everything, Be Anything™.

Requirements

Four to Five (4-5) years of experience with a managed care organization in a Provider Data Management, Credentialing, Network Management, Network Development, and/or Provider Relations role.
Combination of education and work experience required; Associate or Bachelor’s degree preferred.
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, Access, and PowerPoint.
HIPAA & Security Requirements: 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.

Responsibilities

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.
Creating new non-contracted providers, their offices, and payee(s), into the three (3) provider databases; comprehensively reviewing and editing existing non-contracted provider data to facilitate accurate claims processing and the issuance of authorizations.
Comprehensively reviewing, editing, and updating existing provider, office, and payee records as needed and as requested, including review of documentation and reports, and acting on requests from internal and external customers.
Terminating provider, office, and payee records as requested using correct termination reason codes to determine controllable and noncontrollable terminations, requiring extensive review of documentation and reports, as well as acting on requests from internal and external customers.
Managing 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.
Managing “Provider Pick” and “Provider Contract” claims pend queue and providing guidance to Claims on claims processing.
Maintaining IRS standards for Payees and utilizing Tax Identification Number verifications.
Annually, resolving all 1099-B submissions to Versant Health.
Supporting Versant Health Accounts Receivable Department with provider education on Negative Balance accounts and network suspension and reactivations.
Educating and assisting Providers and their office personnel with understanding the uses, importance, and impact of their provider data to Members and the Provider Directory.
Educating and assisting all Versant Health departments with provider data, Provider Directory questions, and various data integrity projects.
Reviewing and processing Provider Directory data updates received from contracted Provider Directory & Outreach vendors to ensure data accuracy; performing updates, corrections, and terminations of provider and office data.
Initiating and/or supporting provider database improvements and communication processes as needed with other departments regarding database enhancements.
Contacting assigned providers to validate required data elements via phone and/or email.
Conducting peer review audits and providing 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.