Temporary Operations Resolution Specialist – Provider Data Management

Jobtailor; Columbus (OH); On-site; USD 60,000 - 78,000; Full time

Job summary

Jobtailor in Columbus, OH seeks a Provider Data Integrity Analyst to manage provider data accuracy and CMS compliance. You will act as a subject matter expert on plan systems and policies, and liaise with internal and external customers to resolve issues.

The role involves audits for CMS rules, preparing credentialing rosters for automated processes, and educating teams on roster formats to support expansion while protecting confidentiality of sensitive information.

Qualifications

• Association or bachelor degree preferred in a relevant field.
• 1–3 years of experience in managed care health insurance.
• Effective communication skills and attention to detail.
• Strong written and verbal communication abilities.
• Analytical and problem-solving capabilities.
• Experience using computer systems and office applications.
• Familiarity with provider credentialing and contracting terminology.
• Basic knowledge of healthcare claims processes.
• Understanding regulatory requirements for health plan data.
• Ability to maintain confidentiality and discretion with sensitive materials.

Responsibilities

• Manage integrity of Health Plan provider data to ensure compliance.
• Serve as SME on plan systems, tools, policies, procedures.
• Act as liaison with internal and external customers.
• Conduct audits for CMS compliance requirements.
• Produce CMS provider data reports for HEDIS purposes.
• Identify root causes of provider data discrepancies.
• Collaborate with Operations Resolution Specialists to resolve issues.
• Prepare initial direct and delegated credentialing rosters for PDL.
• Process PDL rejection reports and correct errors.
• Educate CINs and groups on roster formats for future expansion.
• Perform internal monitoring audits of provider data changes.

Skills

Effective communication

Written communication

Verbal communication

Analytical thinking

Problem solving

Computer systems

Office automation

Provider credentialing knowledge

Contracting terminology

Healthcare claims knowledge

Regulatory awareness

Confidentiality

Education

Associate or Bachelor's degree preferred

Job description

• Manage the integrity of the Health Plan's provider data to maintain compliance with Federal and local requirements
• Serve as department subject matter expert on plan systems, tools, policies, and procedures
• Act as liaison with internal and external customers
• Conduct audits to ensure compliance with Centers for Medicare and Medicaid Services (CMS) requirements
• Produce accurate provider data reports required by CMS for HEDIS purposes
• Identify root causes of provider data discrepancies
• Work alongside Operations Resolution Specialists across the plan to resolve issues
• Prepare initial direct and delegated credentialing rosters for the automated Provider Data Load (PDL) process
• Process PDL rejection reports and correct discovered errors
• Educate CINs and groups on direct and delegated roster formats for future expansion and accurate PDL
• Perform internal monitoring audits of provider data, including demographic changes, TIN additions, and provider terminations

Requirements

• Associate or Bachelor's degree preferred
• One to three years experience preferred in either managed care health insurance
• Effective communication skills
• Strong written and verbal communication skills
• Analytical and problem-solving skills
• Experience using computer systems and office automation applications
• Knowledge of provider credentialing and contracting terminology
• Basic knowledge of healthcare claims process
• Knowledge and competence in regulatory requirements for Health Plan provider data
• Ability to maintain confidentiality and use discretionary discernment with sensitive materials

Core Competencies

Demonstrates expertise in managing provider data integrity and compliance with Federal and local requirements, including knowledge of CMS regulations and provider credentialing processes. Strong analytical, communication, and problem-solving skills are essential for effective collaboration and issue resolution.