Job Title
Provider Data Specialist I
Department
Claims
Exemption Status
Non-Exempt
Requisition #
24945
Direct Reports
N/A
Manager Title
Claims Manager
Pay & Benefits
Estimated hiring range $22.38 - $27.35/hour, 5% bonus target, full benefits.
www.careoregon.org/about-us/careers/benefits
Posting Notes
This role is fully remote but must reside in one of the listed 9 states.
Job Summary
This position is responsible for providing product support to provider data within the QNXT module. Primary tasks include adding, maintaining, and updating provider data records, as well as assistance with database integrity. Accurate and timely provider data plays a critical role in the success of claims payment, OHA Health Systems (DMAP) and CMS encounter data submission, PCP assignment, authorization processing, credentialing, IRS reporting, regulatory projects, and the provider directory.
Essential Responsibilities
Provider Database Maintenance
- Perform accurate and timely data entry into provider database, following Provider Data policies and procedures.
- Provide data management and process knowledge to the organization; assist with projects.
- Investigate and resolve provider and provider contract pended claims as requested by more advanced Provider Data staff; apply claims policies and procedures.
- Monitor call and email queues by reviewing requests and communicating clearly and timely with contracted provider offices and internal customers; research demographic and affiliations changes; make updates to provider database reflecting new information once validated.
- Manage monthly provider rosters received from contracted hospital systems and IPAs by investigating changes and validating information prior to updating QNXT; consult with advanced Provider Data staff to clarify information.
- Complete provider database projects resulting from contracting, configuration, or regulatory changes.
- Sort incoming faxes, PIVs and distribute according to assignments.
- Maintain SharePoint libraries according to unit protocols.
- Enroll providers with OHA Health Systems using MMIS web enrollment portal.
- Reroute critical pieces of return mail including 1099s, live checks and remittance advice by investigating demographic discrepancies and reflecting changes in QNXT.
- Create and maintain security access for provider web portal; troubleshoot and investigate provider portal issues when they arise.
Provider Database Integrity
- Troubleshoot provider setup to support provider reporting, directory, and claims operation.
- Perform testing of new software versions.
Organizational Responsibilities
- Perform work in alignment with the organization’s mission, vision and values.
- Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
- Strive to meet annual business goals in support of the organization’s strategic goals.
- Adhere to the organization’s policies, procedures and other relevant compliance needs.
- Perform other duties as needed.
Experience and/or Education
Required
- Minimum 1 year experience with data entry, data management, or credentialing
Preferred
- 2 years' experience working in health care/insurance
- Experience with managed care and/or project participation
Knowledge, Skills and Abilities Required
Knowledge
- Familiarity with relational databases
- General understanding of or ability to learn managed care and Oregon Health Plan concepts
- Familiarity with Microsoft Office Suite products, especially Excel
Skills and Abilities
- Ability to learn and effectively navigate claims processing technologies, such as QNXT and Facets
- Ability to learn and effectively navigate document management and collaboration platforms, such as SharePoint and Office 365
- Ability to follow policies and procedures in performing job responsibilities
- Ability to develop skills around troubleshooting data integrity issues and root cause
- Ability to learn how to author and maintain process documentation
- Proficient communication skills, including listening, verbal, written, and customer service
- Ability to articulate instructions
- Learning to convey appropriate level of detail effectively to multiple levels of the organization including non-technical staff
- Ability to learn to appropriately communicate status and needs
- General ability to learn to handle multiple priorities and requests
- Demonstrates general initiative and motivation
- Ability to effectively collaborate with coworkers
- Attention to details and deadlines
- Ability to learn to see the big picture
- Developing organizational skills
- Ability to prioritize work based on direction
- Ability to develop analytical and research skills
- Ability to maintain a positive attitude
- Ability to learn governance and process
- Ability to work effectively with diverse individuals and groups
- Ability to learn, focus, understand, and evaluate information and determine appropriate actions
- Ability to accept direction and feedback, as well as tolerate and manage stress
- Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
- Ability to hear and speak clearly for at least 3-6 hours/day
