Provider Relations Representative (52758)

Globalhealth Holdings; Oklahoma City (OK); Hybrid; USD 52,000 - 75,000; Full time

Job summary

GlobalHealth is seeking a provider data QA specialist to ensure accuracy of the provider directory and data integrity across systems. This role supports CMS and NCQA compliance while improving access for Health Plan members in a remote, nationwide setting.

You'll maintain provider/vendor records, respond to inquiries, and collaborate with internal teams to educate providers and uphold HIPAA privacy standards.

Qualifications

• High school diploma or equivalent is required.
• Bachelor's degree preferred.

Responsibilities

• Maintain accurate Provider/Vendor records and Provider Directory.
• Develop and evaluate provider network to ensure access for Health Plan membership.
• Create and verify Provider Data integrity with ongoing monitoring and respond to inquiries.
• Educate and assist providers to maximize data integrity and provider experience.
• Collaborate with internal/external teams to improve network strategies and relations.
• Respond to provider nominations and guide leadership based on network needs.
• Assist with CMS guidelines and NCQA accreditation standards.
• On-board new providers including training to ensure program success.
• Handle Provider Inquiries via emails, CRMs, and surveys in a timely manner.

Skills

Data integrity

Provider relations

HIPAA compliance

Analytical skills

Education

High school diploma

Bachelor's degree preferred

Tools

NPPES data

Job description

Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102

WHO WE ARE

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

WHO YOU ARE

Responsible for quality assurance of the provider data integrity, for responses to provider inquiries with research and resolution, and to insure proper categorization of provider directory.

ESSENTIAL JOB FUNCTIONS

• Assists in maintaining accurate Provider/Vendor records and Provider Directory
• Develop and evaluate the provider network to ensure appropriate access and availability for Health Plan membership
• Create and verify Provider Data integrity with on-going monitoring and responds to daily inquiries in a timely manner
• Educate and assist providers to maximize data integrity and provider experience
• Cultivates and maintains collaborative internal and external relationships to maintain and improve positive interpersonal relations and execute network strategies
• Responds timely to provider nominations by providing guidance and insight to leadership based on network need
• Actively participates and assists in meeting CMS guidelines and NCQA accreditation standards
• Assists in the on-boarding of new providers. This may include training and education to providers to ensure success in the program.
• Resolves Provider Inquiries via Provider Relations email, CRMs, Joint Operating Committees and surveys in a timely manner.
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned

EDUCATION AND EXPERIENCE

• High school diploma or equivalent is required
• Bachelors degree preferred
• At least two years of related experience with a payer or provider organization with responsibility for provider relations, provider credentialing, and/or provider information management required

KNOWLEDGE, SKILLS AND ABILITIES

• Computer Proficiency Demonstrated proficiency in the use of personal computer applications; specific skills to include Microsoft Word, Outlook, Excel v-lookup, and ability to build and compare files using NPPES data and provider taxonomy
• Interpersonal Skills Ability to quickly develop rapport and work effectively and professionally with all levels of personnel
• Problem-Solving Skills Ability to investigate/research problems and issues and to recommend associated corrective actions
• Discretion Ability to manage sensitive or confidential information in a professional and discreet manner

WORK ENVIRONMENT

Current work environment is remote, however, some state exclusions apply.

Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.

TRAVEL

None

SUPERVISORY RESPONSIBILITY

This position has no supervisory responsibilities.

OTHER DUTIES

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.