JOB DESCRIPTION

Job Summary

Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Maintains critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems and application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing.

 

KNOWLEDGE/SKILLS/ABILITIES

Establish and maintain internal standard operating procedures, and enterprise-wide policies and procedures pertaining to Provider functions ensuring alignment with business objectives. Collaborate with departments on issues related to provider, including but not limited to, Configuration, Business Systems, Encounters (inbound and outbound), Claims, Provider Services and Contracting. Assist in design and development of new programs as related to data migrations and implementations of new or existing plans with regards to provider data. Experience in developing business requirement to support automated processed. Organizational expert in responding to legislative and regulatory developments and audits as it relates to provider information. Supports others in facing out to regulators in developing and implementing appropriate Corrective Action Plans for submission of provider network files, etc. Act as an expert in handling complaints and other escalated issues from internal customers. Experience in monitoring daily inventory levels related to provider data updates, ensuring service level agreements are achieved as well as quality measurements; managing production and non-production staff to ensure targets are met.

 

JOB QUALIFICATIONS

Required Education

Bachelor's Degree or equivalent combination of education and experience

 

Required Experience

5+ years industry experience with Medicaid, Medicare and or Market Place operations,

Preferred Experience

2+ years managing provider data, QNXT experience

 2+ years management experience.