Provider Data Quality Rep

The Health Plan Of West Virginia Inc; Wheeling (WV); On-site; USD 38,000 - 54,000; Full time

Benefits offered by this job

Equal Opportunity Employer

Job summary

The Health Plan Of West Virginia Inc is seeking a Provider Data Quality Rep in Wheeling, WV. This clerical, full-time role focuses on maintaining provider data in credentialing systems and ensuring accurate fee tables for claims payments.

Responsibilities include entering credentialing applications, ensuring NCQA and No Surprises Act compliance, and collaborating with the Provider Delivery Services team. A minimum education in health care operations is required.

Qualifications

• Associates degree or high school diploma with health care operations experience.
• Excellent communication and writing skills.
• Experience with Microsoft Office and Adobe Acrobat.
• Understanding of managed care plans and health insurance.
• Strong time management and organizational skills.

Responsibilities

• Maintain participating provider records in Symplr Payer and the claims system.
• Enter newly contracted providers into the system.
• Set up and maintain provider fee tables to ensure correct payments.
• Enter credentialing applications to initiate the credentialing cycle.
• Demonstrate NCQA NET 5 compliance and No Surprises Act requirements.
• Notify members of provider termination per regulations.
• Research and resolve inquiries about provider status and system setup.
• Collaborate with Provider Delivery Services and other departments.
• Assist with NCQA, CMS, and state audits.
• Assist training and development related to provider data quality.
• Maintain non-participating provider and dental records; create new records from claims.
• Resolve data entry claims queue issues; ensure accuracy of payments.

Skills

Excellent communication and writing

Microsoft Office (Excel, Word, Teams)

Adobe Acrobat

Understanding of managed care plans/健康

Education

Associates degree or high school diploma

College degree preferred

Tools

Symplr Payer

Claims processing system

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Provider Data Quality Rep

Provider Delivery Services Full Time Clerical Wheeling, WV, US

Maintain participating provider data in the credentialing/provider data mangement system and the claims operating system, including adding new providers, updating existing providers and terminating providers. Set up and maintain contracted rates to ensure provider contract compliance.

Required:

• Associates degree or high school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience with credentialing, claims, and provider data management.


• Excellent communication and writing skills.


• Experience in Microsoft Office (Excel, Word, Teams) and Adobe Acrobat with the ability to learn applications that support credentialing and provider data management processes.


• General understanding of managed care plans and health insurance.


• Critical thinking abilities along with the ability to work independently.


• Proven time management and organizational skills.

Desired:

• College degree preferred.


• Experience with credentialing and provider data management system.

Responsibilities:

• Maintain participating provider records in symplr Payer and the claims operating system with demographic, Tax ID, or other changes to ensure data accuracy.


• Ensure newly contracted providers are accurately entered into symplr Payer.


• Set up and maintain provider fee tables to ensure correct claims payment.


• Enter credentialing applications to initiate the credentialing cycle.


• Demonstrate compliance with NCQA NET 5, Element A-J and No Surprises Act to accurately populate provider directory information within the timely requirements.


• Demonstrate compliance with NCQA NET 4, Elements A & B and state regulations to notify members of a provider termination within the timely requirements.


• Manage returned mail, such as checks and EOPs, by researching and facilitating issue resolution,


• Adhere to all The Health Plan (THP) policies and procedures, as well as, following regulations and standards established by NCQA, CMS, BMS, and the states where THP serves its members.


• Research and resolve internal and external inquiries regarding provider status and system setup to ensure quality control.


• Work collaboratively with the Provider Delivery Services team as well as all internal departments.


• Assist with NCQA, CMS, BMS, state and internal audits.


• Assist with training and development of employees related to provider data quality processes.


• Maintain non-participating provider and dental records in the claims processing system with demographic, Tax ID, or other changes to ensure accuracy of information.


• Create new non-participating provider and dental records in the claims processing system based on the information received on a claim.


• Resolve data entry claims queue issues including data entry of non-participating providers.


• Basic pay class assignment and maintenance to ensure the accuracy of claims payment.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

8:00am-9:00pm

40