About this role
American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Kansas, Missouri, Oklahoma, Georgia, Mississippi, Florida, Texas, Utah and Tennessee. For more information, visit AmHealthPlans.com .
JOB SUMMARY:
The Provider Data Specialist ensures all contracted and non-contracted provider demographics and payment methodologies are accurate and current with the plans operating systems and verifies the integrity of provider demographic data. This position is also responsible for assisting and supporting reporting functions of provider data to appropriate agencies, committees and management.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:
- Maintain provider demographic information through initial contracting submission, credentialing and paper or electronic updates submitted by providers, customer service representatives, Network Services Department, Claims Department, audits, and other sources
- Reviews data and corrects errors as received
- Keep current on all information received; remain within departmental standards
- Download provider credentialing (CAQH) applications; confirm accuracy
- Extract and report data for analyses
- Represent the provider network department on company IT projects such as reporting and tracking provider calls and complaints, or for the support, coordination, and production of the provider directory
- Develop and maintain standards for database integrity and quality assurance, coordinate corrective actions to clean database
- Contact providers in a timely manner to obtain missing and/or incorrect documentation; follow up as necessary
- Participate on calls with network services staff to assist with troubleshooting; recommend enhancements to related programs
- Assist with the preparation of agendas; organize handouts and other materials; take minutes during Credentialing Committee meetings
- Assist with the facilitation of the Credentialing Committee approval and denial notification process (e.g., welcome and denial letters) with other Network Services Department staff
REQUIRED SKILLS:
- Typing skills at least 40+ wpm
- Ability to accurately enter data into information system as instructed
- Ability to prioritize workload and function well in a changing environment
- Be efficient, effective and assertive in both written and spoken communications
- Detail oriented and have the ability to seek and implement efficient processes
REQUIRED QUALIFICATIONS:
- Education:
High School Diploma / GED
- College Coursework / Degree preferred
- Experience:
Data entry in a deadline driven environment
- Previous credentialing experience
OTHER REQUIREMENTS:
- Must be willing and able to work flexible hours
- Travel required
- Position may require unscheduled overtime
- Microsoft Office including Outlook, Excel and Word
- Must be able to multi-task in a fast past environment
WORKING CONDITIONS:
- Work is typically performed at home in a dedicated office space
- Typical working hours are 8:00 AM to 5:00 PM but negotiable
- Position may require flexible hours
- Travel may be required to come into corporate office if located within 40 miles
EQUAL OPPORTUNITY EMPLOYER
Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made.