Provider Data Representative

Accede Solutions Inc (accedesolution.com); United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Accede Solutions Inc in the United States seeks a Provider Data Specialist to ensure data integrity across credentialing, enrollment, and directory accuracy. You will collaborate with Provider Relations, Credentialing, and Claims Operations to keep provider information complete, timely, and compliant with standards.

You will maintain roster records, validate NPIs, TINs, specialties, and EFT details, and support onboarding and re-credentialing.

Qualifications

• Bachelor's degree preferred.
• 2–5 years of experience in provider data, credentialing, enrollment, or health plan operations.
• Strong analytical skills and proficiency in Microsoft Excel.
• Exceptional attention to detail and accuracy.
• Experience with federal or government-sponsored programs preferred.
• Knowledge of provider directory regulatory requirements.

Responsibilities

• Maintain accurate provider demographic, enrollment, and participation records.
• Validate NPIs, TINs, specialties, and EFT details.
• Ensure data readiness for onboarding and re-credentialing.
• Reconcile rosters across credentialing, enrollment, and directory systems.
• Collaborate with Provider Relations, Credentialing, and Provider Data teams.
• Produce provider data quality reports and audit results.

Skills

Data governance

Analytical thinking

Microsoft Excel

Attention to detail

Education

Bachelor's degree

Tools

Enrollment systems

Provider data platforms

Job description

The role ensures provider data integrity to support accurate claims payment, credentialing compliance, provider directory accuracy, and network participation. The Representative partners with Provider Relations, Credentialing, Provider Data, Claims Operations, and contracting to keep provider information complete, accurate, timely, and compliant with organizational standards.

• Key Outcomes & Success Metrics Directory accuracy & completeness: Meet internal standards and regulatory expectations; reduce member/provider complaints due to directory errors.
• Maintenance timeliness: Process updates, additions, terminations, and changes within SLAs; reduce cycle time and backlog.
• Data integrity: Improve audit scores; lower claims‑ impacting data error rates; maintain accurate NPIs, TINs, specialties, practice locations, affiliations, licenses, and EFT details.
• Roster reconciliation effectiveness: Validate rosters against credentialing, enrollment, terms & conditions, claims, and directory data; correct discrepancies promptly.
• Credentialing & enrollment support: Ensure data readiness for onboarding and re-credentialing; reduce participation activation delays.
• Operational reporting: Provide clear dashboards and logs for productivity, turnaround times, accuracy, and issue remediation.
• Data Intake & Maintenance OperationsProcess provider roster submissions and updates.
• Maintain accurate provider demographic, enrollment, and participation records.
• Validate and update NPIs, TINs, specialties, practice locations, EFT details, and affiliations.
• Ensure timely changes supporting accurate claims payment and directory publication.
• Roster Reconciliation Reconcile provider rosters against credentialing, claims, enrollment, and directory systems.
• Identify discrepancies impacting participation, claims payment, or directory accuracy.
• Coordinate corrections with Provider Relations, Credentialing, and Provider Data teams.
• Credentialing & Enrollment SupportValidate provider demographic information for credentialing/re-credentialing.
• Identify and resolve enrollment and participation discrepancies.
• Ensure data requirements is complete for onboarding and participation activation.
• Data Quality & GovernanceAudit provider records for completeness, accuracy, and compliance.
• Monitor directory accuracy, quality scores, and claims‑ impacting error rates.
• Support development of data standards, QA programs, and process improvements.
• Claims & Operational SupportIdentify provider data issues affecting claims adjudication, reimbursement, and participation.
• Collaborate with Claims Operations to resolve data discrepancies; support root‑ cause analysis and remediation.
• Reporting & AnalyticsProduce provider data quality reports, discrepancy logs, and audit results.
• Track maintenance productivity, turnaround times, and accuracy metrics.
• Provide insights to leadership to guide operational improvements.
• Provider & Stakeholder CommunicationCommunicate data requirements and discrepancies to credentialing, enrollment, and provider relations teams.
• Provide clear documentation for provider updates and requests.
• Process Improvement & ToolingRecommend system enhancements, automation opportunities, and updated workflows.
• Support implementation of new processes, templates, and operational tools.

Qualifications

• RequiredBachelor's degree preferred.
• 2–5 years of experience in provider data, credentialing, enrollment, or health plan operations.
• Strong analytical skills and proficiency in Microsoft Excel.
• Exceptional attention to detail and accuracy.
• PreferredExperience supporting federal or government‑ sponsored healthcare programs.
• Knowledge of provider directory regulatory requirements and healthcare data standards.
• Experience with provider portals, enrollment systems, or enterprise provider data platforms.
• Skills & CompetenciesData governance and quality management.
• Analytical thinking and problem solving.
• Strong written and verbal communication.