Provider Data Specialist_NO

Socket.dev; City of Troy (NY); On-site; USD 29,000 - 33,000; Full time

Job summary

Versant Health is seeking a Provider Data Specialist to educate, verify, monitor, and manage provider, office, and payee data across national networks. You will update records, ensure accuracy for claims processing and authorizations, and conduct audits to support data integrity.

The role requires experience in provider data management within a managed care setting, strong privacy discipline, and familiarity with CMS Provider Directory regulations.

Qualifications

• Four to Five (4-5) years of experience with a managed care organization in a Provider Data Management, Credentialing, Network Management, Network Development, and/or Provider Relations role
• Combination of education and work experience required; Associate or Bachelor’s degree preferred
• Capable and comfortable dealing with Protected Health Information (PHI), Personal Identifiable Information (PII), sensitive, and confidential information with discretion and trust
• Experience must include direct responsibility for managing provider, office and payee data and/or claims processing

Responsibilities

• Create new providers, offices, and payees into provider databases based on contracting and credentialing data
• Review and edit existing provider data to ensure accurate claims processing and authorizations
• Terminate provider, office, and payee records using correct termination codes after reviewing documentation
• Manage provider data across three provider databases and update rosters as needed
• Support provider data education across departments and interact with internal/external customers

Skills

PHI/PII handling

Data management

Provider data

CMS regulations

Education

Associate or Bachelor's degree

Tools

Excel

Word

Access

PowerPoint

Job description

Provider Data Specialist

Who are we?

Versant Health is one of the nation’s leading administrators of managed vision care, serving millions of our clients’ members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision.

As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, no-cost-to-you vision insurance for you and your qualified dependents. We are also invested in your success. There are many opportunities for advancement and development throughout all stages of your career with us.

See how you can make a difference with the support of strong leadership and a team environment.

See Everything, Be Anything.

What are we looking for?

The Provider Data Specialist role is responsible for educating, verifying, monitoring, and accurately managing all of Versant Health’s two national networks of 80,000+ Ophthalmology and Optometric practitioner’s and office’s demographic and payee data. The role performs additions, changes, and terminations to Versant Health’s provider data systems to positively effect the accuracy of the Provider Directory, Utilization Management and authorizations, and claims processing. The Provider Data Specialist role will also perform periodic audits, maintenance, and troubleshooting of provider, office, and payee data utilizing the National Practitioner Identifier (NPI) Registry, state’s Provider Master Files for Medicaid Registration, and Tax Identification programs.

Where you will have an impact

• Directly responsible for creating newly contracted providers, their offices, and payee(s), into the three (3) provider databases based on data received via contracting, credentialing reports, and direct provider submissions Directly responsible for creating new non-contracted providers, their offices, and payee(s), into the three (3) provider databases; comprehensively reviews and edits existing non-contracted provider data to facilitate accurate claims processing and the issuance of authorizations.
• Directly responsible to comprehensively reviewing, editing, updating existing provider, office, and payee records as needed and as requested. Requires review of documentation and reports, as well as acting on requests from internal and external customers.
• Directly responsible to terminate provider, office, and payee records as requested using correct termination reason codes to determine controllable and noncontrollable terminations. Requires extensive review of documentation and reports, as well as acting on requests from internal and external customers.
• Manage complex Retailer and Provider Group data by periodically receiving and comprehensively reviewing the provider databases and rosters and performing updates to the three (3) provider databases.
• Directly responsible for managing “Provider Pick” and “Provider Contract” claims pend queue and providing guidance to Claims on claims processing.
• Maintain IRS standards for Payees and utilize Tax Identification Number verifications.
• Annually, resolve all 1099-B submissions to Versant Health
• Support Versant Health Accounts Receivable Department with provider education on Negative Balance accounts and network suspension and reactivations
• Educate and assist Providers and their office personnel with understanding the uses, importance, and impact of their provider data to Members and the Provider Directory
• Educate and assist all Versant Health departments with provider data, Provider Directory questions, and various data integrity projects.
• Review and process Provider Directory data updates received from contracted Provider Directory & Outreach vendors to ensure data accuracy; perform updates, corrections, and terminations of provider and office data.
• Initiate and/or support provider database improvements and communication processes as needed with other departments regarding database enhancements.
• Contact assigned providers to validate required data elements via phone and/or email.
• Conduct peer review audits and provide feedback to reduce errors and improve processes and performance, maintaining current provider data to ensure the quality of the network, and may be responsible for representing the provider network area on department related IT projects.

What’s necessary to do the job?

• Four to Five (4-5) years of experience with a managed care organization in a Provider Data Mangement, Credentialing, Nework Management, Network Deveopment, and/or Provider Relations role
• Combination of education and work experience required; Associate or Bachelor’s degree preferred
• Capable and comfortable dealing with Protected Health Information (PHI), Personal Identifiable Information(PII), sensitive, and confidential information with discretion and trust
• Experience must include direct responsibility for managing provider, office and payee data and/or claims processing.
• Experience working with provider networks and healthcare providers.
• Knowledge and experience in CMS Provider Directory regulations
• Proficiency in MicroSoft Office Excel, Word, Excel, Access, and Power Point

HIPAA & Security Requirements

All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Versant Healthis a proud Equal Employment Opportunity and Afformative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.

The wage range for applicants for this position is [$22.50].

All incentives and benefits are subject to the applicable plan terms.