Healthcare Configuration and Data Integrity Manager

Provider Network Solutions, LLC; Miami (FL); On-site; USD 90,000 - 120,000; Full time

Job summary

Provider Network Solutions, LLC seeks a Configuration and Data Integrity Manager to implement and oversee claims, provider configuration, eligibility, and provider data management. You will ensure secure data exchanges, integrity, and availability, and guide how data is used across departments.

The role involves coordinating with internal teams and external parties, auditing database compliance, and supporting business users in data management and reporting needs.

Qualifications

• 3–5 years of Claims Processing experience required.
• 1–2 years’ experience in healthcare data management.
• Broad knowledge of medical terminology, customer service, claims processing and/or cost containment, and coordination of benefits and diagnosis coding.

Responsibilities

• Responsible for benefit configuration, copays, deductibles, coinsurance and MOOP in the TPA system.
• Manage provider records configuration and contract rate loads, vendor and location data.
• Provide configuration support for provider contracts and upgrades.
• Conduct unit testing to ensure design meets specifications for product upgrades or releases.
• Interpret contracts and convert terms to configuration parameters.
• Quality control of all information uploaded in the TPA system: provider data, fee schedules, network assignments.
• Collaborate with provider call center, clinical and claims teams to verify configurations.
• Provide system configuration support based on changing business needs.
• Review and propose changes to existing configuration processes.
• Analyze and resolve claims workflow issues related to benefit and contract configuration.

Skills

Claims processing

Healthcare data management

Customer service

Coordination of benefits

Data quality

Tools

Microsoft Excel

Microsoft Outlook

Microsoft Access

Microsoft Word

Job description

Description

Position Summary

The Configuration and Data Integrity Manager is responsible for implementing and interpreting the organization's overall claims, provider configuration, eligibility and provider database management, security, and operations. The Configuration Manager will work with internal departments and external organizations to assure secure data exchanges, integrity, reliability, and availability; plans, organizes and coordinates activities related to the analysis and implementation of network database systems; provides technical guidance and database compliance audits; and consults with business users regarding the use and management of data.

Duties and Responsibilities

• Responsible for benefit configuration covered services, copay, deductibles, coinsurance and max out of pocket in TPA system. Ensure mapping and testing behind the scenes and maintain Matrix of Benefit Packages


• Responsible for provider records configuration and contract rate load create vendors, practice locations, medical group, networks, reimbursement rate. Collaborate with Provider Relations Department and Credentialing to ensure Responsible for work distribution and resource management of configuration specialist and data integrity specialist.


• Configuration support to provider contracts-question if specific agreement received can be entered as noted.


• Conduct unit testing to ensure design meets specifications as it relates to product upgrades or new releases.


• Responsible for accurately interpreting specific contracts as well as additional business requirements and converting these terms to configuration parameters.


• Quality control of all information uploaded in TPA system, i.e., Provider data, fee schedules, network assignment, team member’s responsibilities.


• Collaborate with provider call center, clinical and claims department when asked to verify specific provider configuration or benefit configuration information.


• Provide system configuration support to organization based on changing business needs.


• Review and recommend changes to existing configuration processes.


• Analyze and resolve Claims Workflow regarding Benefit & Contract configuration issues in a in with 3 business days.


• Provide technical guidance to Data Integrity Specialist in their assigned job duties.


• Oversee Configure Medicare/Medicaid/Commercial interest rates in TPA system.


• Resolve Eligibility Issues with Health Plans.


• Validate reports ran by Data Integrity Specialist on a weekly, monthly, and quarterly basis.


• Load and Maintain Fee Schedule in TPA System


• Act as liaison between Corporate and the health plan regarding programming development needs related to reporting.

Requirements

Knowledge

• 3-5 years of Claims Processing experience required.


• 1-2 years’ experience in healthcare data management.


• Broad knowledge of medical terminology, customer service, claims processing and/or customary and reasonable cost containment, and coordination of benefits and diagnosis coding.

Skills

• Advanced knowledge of Microsoft applications: Outlook, access database, excel, word and basic computer navigation.