Company :United Concordia Dental
Job Description :
This job is responsible for corporate provider enrollment and provider file maintenance across all markets. This includes, enrollment, contracting and demographic provider information. Incumbent ensures compliance with BCBS and CMS requirements, DOH regulations, internal, private business and governmental audits. Responsible for reviewing and processing additions, updates, and deletions of provider information in the Provider File database. Ensures executions of data entry and updates are completed in a timely and accurate manner.
1. Maintain accurate data in provider file data systems. Common transactions include:
- Maintaining and initial setup of assignment accounts (AA) from the AA applications
- Updating group and provider affiliations from AFBs and written requests
- 1099 tax ID updates
- UPIN/PTAN and/or Medicare Welcome Letter information
- State license update
- Enumerating providers
- Name changes, demographic data updates, specialty changes
- Hospital affiliations, network affiliations, network terminations
- Facility Agreement data, Institutional non-contracted files.
2. File Maintenance Analysis.
- Applying complex and detailed guidelines in the review process of the submitted requests
- The documentation application must comply with BCBS, DOH, CMS, MSBCBS and Highmark requirements.
- Routinely contact external sources such as the Provider offices, state licensing agencies and provider reps to collect or clarify information or documentation, which in turn must be reviewed and evaluated against the established guidelines
- Ensure the file meets all regulations prior to updating the provider file
3. Data Integrity.
Contact external sources to collect or clarify information or documentation which in turn must be reviewed and evaluated against the established guidelines and procedures to ensure the file meets all policy and procedures in conjunction with regulations. Maintain and update internally required data elements which include but are not limited to:
- Assigned Blue Shield provider numbers
- National Provider Identifier (NPI)
- CMS required provider identifiers for compliance with corporate and federal contracts.
- This individual will be also responsible to educate providers for obtaining and updating provider identifiers.
4. Other duties as assigned or requested.
- High School Diploma or GED
- One year of experience in Provider Data Management, Credentialing, Customer Services or Claims.
LICENSES OR CERTIFICATIONS
- Ability to communicate with both providers and customers
- Microsoft Office
- Typing/Computer Proficiency
- Problem Solving Skills
Language (Other than English)
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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