[Hiring] Provider Data Specialist @Versant Health

Role Description

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 practitioners and offices' demographic and payee data. The role performs additions, changes, and terminations to Versant Health’s provider data systems to positively affect 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 for comprehensively reviewing, editing, and updating existing provider, office, and payee records as needed and as requested.
• Directly responsible for terminating provider, office, and payee records as requested using correct termination reason codes.
• Manage complex Retailer and Provider Group data by periodically receiving and comprehensively reviewing the provider databases and rosters.
• 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.
• 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.

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.
• Experience working with provider networks and healthcare providers.
• Knowledge and experience in CMS Provider Directory regulations.
• Proficiency in Microsoft Office Excel, Word, Access, and PowerPoint.

Requirements

• 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).
• Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times.
• Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Benefits

• 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.
• Opportunities for advancement and development throughout all stages of your career.

Company Description

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.