Healthcare Configuration and Data Integrity Manager

Provider Network Solutions, LLC; Miami, Northern (FL, KY); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Provider Network Solutions, LLC in Miami, FL is looking for a Configuration and Data Integrity Manager to lead the configuration of benefits, provider records, and network relationships. The role focuses on secure data exchanges, integrity, and availability across claims, eligibility, and provider databases, with collaboration across multiple internal teams.

The candidate will guide data governance, perform audits, and support system configurations for contracts and rate loading while ensuring

Qualifications

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

Responsibilities

• Configure and test benefit configuration and copay/deductible settings in the TPA system.
• Load and manage provider records, contracts, locations, networks and rates; coordinate with Provider Relations and Credentialing.
• Perform unit testing for product upgrades or new releases and ensure designs meet specifications.
• Interpret contracts and business requirements to configuration parameters; ensure data integrity and quality control of provider data, fee schedules and network assignments.
• Collaborate with provider call center, clinical and claims departments to verify provider configurations.
• Provide system configuration support based on changing business needs and review changes to processes.

Skills

Outlook

Excel

Access

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.