The Provider Data Integrity Specialist creates and maintains all Provider Data configured in our claims payers' systems per all state and federal regulations as well as company policies are adhered to. In this role the Provider information configured and maintained should include but is not limited to demographic, reimbursement, contractual, network status and billing information. The integrity of this data is crucial to our members and providers to ensure access to care and accurate claims payment.
Must Have:
Associate Degree or a minimum of 2 years' experience in health insurance or a health care operations or related field
Minimum of two (2) years' data entry experience
Extensive knowledge of health insurance, insurance laws and regulations, claims processing, medical and insurance terminology
Knowledge of the provider credentialing and contracting process as it relates to all downstream provider configuration and claims payment
Knowledge of cross-functional software module; Electronic Data Interchange (EDI) claim submission, provider remittance advice and provider timely and corrected 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.
Ability to retrieve and interpret analytical data to determine root cause analysis and solution for complex issues.
Strong organizational skills
Strong data analysis skills
Knowledgeable of provider, facility and reimbursement mechanisms