The Health Plan (THP) ยท 3 days ago
Provider Data Quality Representative
Wheeling, WV
Full-time
Onsite
Entry Level
2+ years expThe Health Plan (THP) is focused on maintaining the integrity of provider data within their systems. The Provider Data Quality Representative will be responsible for updating and managing provider records, ensuring compliance with regulations, and supporting internal audits and training related to data quality processes.
Health CareInsuranceNon ProfitWellness
Responsibilities
Maintain participating provider records in symplr Payer and the claims operating system with demographic, Tax ID, or other changes to ensure data accuracy
Ensure newly contracted providers are accurately entered into symplr Payer
Set up and maintain provider fee tables to ensure correct claims payment
Enter credentialing applications to initiate the credentialing cycle
Demonstrate compliance with NCQA NET 5, Element A-J and No Surprises Act to accurately populate provider directory information within the timely requirements
Demonstrate compliance with NCQA NET 4, Elements A & B and state regulations to notify members of a provider termination within the timely requirements
Manage returned mail, such as checks and EOPs, by researching and facilitating issue resolution
Adhere to all The Health Plan (THP) policies and procedures, as well as, following regulations and standards established by NCQA, CMS, BMS, and the states where THP serves its members
Research and resolve internal and external inquiries regarding provider status and system setup to ensure quality control
Work collaboratively with the Provider Delivery Services team as well as all internal departments
Assist with NCQA, CMS, BMS, state and internal audits
Assist with training and development of employees related to provider data quality processes
Maintain non-participating provider and dental records in the claims processing system with demographic, Tax ID, or other changes to ensure accuracy of information
Create new non-participating provider and dental records in the claims processing system based on the information received on a claim
Resolve data entry claims queue issues including data entry of non-participating providers
Basic pay class assignment and maintenance to ensure the accuracy of claims payment
Qualification
Required
Associates degree or high school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience with credentialing, claims, and provider data management
Excellent communication and writing skills
Experience in Microsoft Office (Excel, Word, Teams) and Adobe Acrobat with the ability to learn applications that support credentialing and provider data management processes
General understanding of managed care plans and health insurance
Critical thinking abilities along with the ability to work independently
Proven time management and organizational skills
Preferred
College degree preferred
Experience with credentialing and provider data management system
Company
The Health Plan (THP)
The Health Plan is a clinically-driven, technology-enhanced, and customer-focused health maintenance organization that manages and improves the health and well-being of its members.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Ryan J. Ralston
Chief Financial Officer
Bob Roset
Senior Vice President, Information Systems (CIO)
Company data provided by crunchbase