Temporary Operations Resolution Specialist – Provider Data Management

Jobtailor; Kentucky; On-site; USD 52,000 - 70,000; Full time

Job summary

Jobtailor in Kentucky is seeking a detail-oriented professional to manage provider data integrity for a health plan. You will audit CMS compliance, troubleshoot data inconsistencies, and coordinate credentialing rosters for automated data loads, while educating internal teams on roster formats for expansion.

You will serve as a subject matter expert on plan systems and regulatory requirements, producing CMS-required reports and ensuring confidentiality when handling sensitive materials.

Qualifications

• Associate or Bachelor’s degree preferred.
• One to three years experience preferred in 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.

Responsibilities

• Manage the integrity of the Health Plan’s provider data to maintain compliance with Federal and local requirements.
• Serve as a 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 CMS requirements
• Produce accurate provider-data reports required by CMS for HEDIS purposes
• Identify root causes of provider-data discrepancies and work with Operations Resolution Specialists across the plan to resolve issues
• Prepare initial direct and delegated credentialing rosters for the automated Provider Data Load process
• Process Provider Data Load rejection reports and correct errors
• Educate CINs, groups, and others on roster formats for future expansion
• Conduct internal monitoring audits of provider data, including demographic changes, TIN additions, and provider terminations

Skills

Provider Data Management

Compliance Auditing

Credentialing Knowledge

Analytical Problem-Solving

Effective Communication

Education

Associate or Bachelor’s degree preferred

Tools

Provider Data Load Processing

Healthcare Claims Knowledge

Data Reporting for HEDIS

Regulatory Compliance Knowledge

Office Automation Applications

Job description

• Manage the integrity of the Health Plan’s provider data to maintain compliance with Federal and local requirements
• Serve as a 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 CMS requirements
• Produce accurate provider-data reports required by CMS for HEDIS purposes
• Identify root causes of provider-data discrepancies and work with Operations Resolution Specialists across the plan to resolve issues
• Prepare initial direct and delegated credentialing rosters for the automated Provider Data Load process
• Process Provider Data Load rejection reports and correct errors
• Educate CINs, groups, and others on roster formats for future expansion
• Conduct 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 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 regulatory requirements, including CMS standards. Proficient in conducting audits, resolving discrepancies, and educating stakeholders on provider data processes.

Highest-signal resume keywords

• Provider Data Management
• Compliance Auditing
• Credentialing Knowledge
• Analytical Problem-Solving
• Effective Communication

Hard Skills

• Provider Data Load Processing
• Healthcare Claims Knowledge
• Data Reporting for HEDIS
• Regulatory Compliance Knowledge
• Office Automation Applications

Soft Skills

• Effective Communication Skills
• Strong Written Communication
• Strong Verbal Communication
• Analytical Skills
• Problem-Solving Skills

Industry Keywords

• Managed Care
• Health Insurance
• Provider Credentialing
• CMS Requirements
• Confidentiality