United Concordia Companies Inc
Job Description :
I. GENERAL OVERVIEW:
This section contains a synopsis of the main purpose(s) or functions(s) of the job, indicating what is done. This information will be used to develop the position posting.
This position 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.
II. ESSENTIAL RESPONSIBILITIES:
This section lists the major duties and responsibilities of the position. This is not an exhaustive list of all job duties/functions/attributes. Depending on Role, essential responsibilities may also include oversight and management of people and functions described below.
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.
Education, Licenses/Certifications, and Experience (For Experience requirements please see appropriate role/level guide. If not applicable, list experience requirements below.)
Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job. Preferred
Provider File Representative (Assoc & Intermediate)
- High School Diploma or GED
- One to two years of experience in Provider Data Management, Credentialing, Customer Services or Claims.
IV. SCOPE OF RESPONSIBILITY (People Management Responsibility)
Does this role supervise/manage other employees? NoX □ Yes □
If yes, indicate the number of direct reports:
V. WORK ENVIRONMENT
Most company positions are performed in a normal office environment. Please use this section to describe unusual work conditions, such as exposure to high noise levels, temperature extremes, etc. If ‘none, ‘please indicate with ‘Not Applicable.’
Is Travel Required?
No X □ Yes □
Unusual Working Conditions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
This job requires the ability to work independently and as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.
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.
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