About the Role
This position is responsible for interpreting, analyzing, researching and maintaining accuracy of provider file data across multiple databases, including the accuracy of the provider directory.
To be successful in this role, you:
- Have one (1) year experience in a healthcare/insurance setting, Managed Care or Commercial health insurance, Provider Data Services, Provider Network Administration.
- Have a minimum of one (1) year’s work experience with Provider Relations, Customer Service, Claims or Provider Data Analysis preferred.
- Have data entry, data interpretation, and analytical problem-solving abilities.
- Have experience with Microsoft Office applications such as Excel, Word, and Outlook.
Essential functions and Roles and Responsibilities:
- Act as the technical provider data expert, following state and federal guidelines, and Community Health Plan of Washington (CHPW) provider contracts.
- Prepare, categorize, and reconcile source documents. Identify and interpret data to be updated in claims and credentialing systems, and online provider directory.
- Accurately add and update provider data in appropriate database(s).
- Prepare Provider Add Change Term (PACT) forms to submit for provider and vendor record changes in the claims payment system. Resolve issues with PACT forms.
- Serve as a technical provider data contact for providers, acting as a liaison regarding provider data updates, issues, claims questions.
- Research, resolve and respond to claims processing and provider reimbursement issues related to contract payment and accurate configuration of provider data in the claims system.
- Provide feedback to the Configuration team to ensure provider contracts are configured in the system correctly.
- Initiate team projects that enhance quality assurance, streamline workflow, and identify process improvements.
- Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.
Knowledge, Skills, and Abilities:
- Ability to gather and interpret data, analyze, summarize results, and create reports.
- Knowledge of state and federal regulatory requirements as it relates to the accuracy and content of provider data, including provider directory.
- Organizational skills and attention to detail.
- Oral and written communication skills.
- Ability to manage time and meet deadlines.
As part of our hiring process, the following criteria must be met:
- Complete and successfully pass a criminal background check
Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.
- Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency
- Vaccination requirement (CHPW offers a process for medical or religious exemptions)
- Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.
Compensation and Benefits:
The position is FLSA Non-Exempt and is eligible for overtime. Based on market data, this position grade is 41 and has a 5% annual incentive target based on company, department, and individual performance goals.
CHPW offers the following benefits for Full and Part-time employees and their dependents:
- Medical, Prescription, Dental, and Vision
- Telehealth app
- Flexible Spending Accounts, Health Savings Accounts
- Basic Life AD&D, Short and Long-Term Disability
- Voluntary Life, Critical Care, and Long-Term Care Insurance
- 401(k) Retirement and generous employer match
- Employee Assistance Program and Mental Fitness app
- Financial Coaching, Identity Theft Protection
- Time off including PTO accrual starting at 17 days per year
- 40 hours Community Service volunteer time
- 10 standard holidays, 2 floating holidays
- Compassion time off, jury duty
Sensory/Physical/Mental Requirements:
Sensory*:
- Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.
Physical*:
- Extended periods of sitting, computer use, talking, and possibly standing.
- Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
Mental:
- Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.
Work Environment:
Office environment. Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.