Provider Data Integrity Specialist

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.

Duties and Responsibilities

Responsibilities include, but are not limited to:

• Responsible for accurate and timely maintenance of provider configuration in accordance with state and federal laws and regulations.
• Serve as the subject matter expert regarding provider configuration in the claims processing system(s) and its impact to member access to care, claims processing and provider reimbursement.
• Monitor proposed/approved changes to state and federal law, assess the impact on provider configuration and institute changes as required to remain compliant with regulations governing the company.
• Assist in the timely maintenance of the Provider Directory, Provider Manual and all Provider content listed on the company website.
• Assist in recurring survey to providers and operationalizes any needed output from such surveys
• Work cross-organizationally (e.g. Credentialing, Claims, Provider Relations, Provider Contracting etc.) to assist in resolving any issues tied to provider data, research of potential issues and provide guidance on any system projects or enhancements.
• Responsible to extract, review and provide quality control on provider configuration to ensure consistency in all applicable software.
• Respond to all provider credentialing and contracting requests in accordance with all regulated turnaround times.
• Perform thorough quality review of all completed provider data updates on all systems to ensure accuracy of data.
• Liase with vendor and business partners to ensure provider data is clear and accurate, adhering to all internal policies and procedures.
• Provide quality oversight with all internal business and external vendors; holding them accountable to regulated service level agreements, escalating when necessary.
• Communicate directly with Providers to implement new requests, solution for issues or provide status updates.
• Perform regular provider audits, including but not limited to roster reconciliation, claims review and cross systems comparisons to ensure quality.
• Responsible for sections of NCQA accreditation reports and artifacts to support accreditation.
• Control access to our network for all providers per state and federal laws and regulations
• Provide guidance to Provider Communications team to review and supply input on all external provider communications.
• Maintain and update as needed, all electronic submission requests from providers. Updating these forms as needed to support corporate projects and initiatives.
• Create and maintain all Provider Data Integrity desktop procedures, policy and procedures, workflows, and business continuity planning.
• Works closely with the Enrollment team to ensure member ID cards and letters are sent timely when required by state and federal regulations.
• Collaborate with Providers directly and or Provider relations to terminate PCP's and reassign members as needed.
• Research and provide guidance or takes actions on claims pending for potential set-up issues.
• Work multiple weekly oversight reports built to enhance quality, identifies new reports as needed.
• Assist Provider Contracting to ensure our network meets and reflects appropriate accessibility for members.
• Claim processing oversight and impact analysis on all adjustments made due to an update in provider data.
• Responsible to identify internal and external opportunities for provider education.
• Responsible to identify and, as approved, implement opportunities for process improvement both internally and externally.
• Work on special projects as assigned by Supervisor
• Identify cost saving initiatives or opportunities and provides documentation to support analysis
• Perform other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

• Associate degree preferred or a minimum of two (2) years' experience in health insurance or a health care operations or related field
• Minimum of two (2) years' data entry experience. Six (6) years data entry experience in lieu of a degree
• Extensive knowledge of health insurance, insurance laws and regulations, claims processing, medical and insurance terminology
• Proven ability to work cross-organizationally to achieve the goals of the organization and department.
• 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
• Strong Microsoft Excel skills

Preferred:

• Bachelor's degree
• Proficient in Excel
• Experience in HealthRules or similar Claims Payer
• Detailed knowledge of government healthcare program regulations
• Experience working with Cognos
• Knowledge of Microsoft SharePoint
• Experience using JIRA
• Knowledge of Streamline Verify and License Validation

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.