Provider Data Resolution Specialist

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.


Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary


Ensures accurate, timely maintenance, and synchronization of critical Provider data on all Provider databases, and systems such as Claims, Data Management, and Authorization/Referral systems. Accesses and utilizes multiple software applications. Applies business rules and knowledge of Provider contract language, pricing and reimbursement methodologies to each database/system to validate Provider information in all systems. Communicates with internal and external customers by phone and email to clarify data and follow-up on issues, working under timeline, accuracy and production targets. Requires the ability to manage a large amount of complex information, communicate clearly, and draw sound conclusions. Performs simple credentialing activities including performing primary source verifications and entering the initial data of potential Providers into the Provider database and credentialing system(s). Collaborates with the Provider Data Specialists and provides clear instructions to correct data issues. Ensures correct reimbursement and Provider data is housed in all downstream systems.


Education & Experience

Required:

• High School Diploma or GED
• If supporting TRICARE contract, must be a U.S. Citizen
• If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DOD) background adjudication
• 2 years of varied responsible experience with computer database programs
• 2 years of Health Care experience such as claims, provider data or authorization or referral processing
• Experience with Microsoft Suite (including, but not limited to, Word, Excel and Outlook)

Preferred:

• 1+ years of Health care claims resolution experience
• Experience using a Provider Data Management System, Claims System, or Authorization/Referral system


Key Responsibilities


• Resolves Provider data discrepancies related to claims processing, including contract reimbursement rates within the allotted timeframe.
• Manages daily follow up of Provider data correction requests and issues to ensure databases are current and accurate.
• Ensures and maintains accurate data within the Provider Claims and Authorization databases.
• Contacts providers to verify all credentialing, claims, and billing information.
• Ensures appropriate tax documentation is obtained and imaged for Provider files.
• Corrects reimbursement issues within claims payment system.
• Develops, maintains, and processes reimbursement terms ensuring correct claims payment and downstream processing.
• Reviews Provider contract language and identifies when a contract is out of compliance. Processes Provider contracts, run reports, and responds to inquiries regarding contract compliance issues; images and indexes contracts and return images to network subcontractors; conducts quality assurance activities to ensure image quality and completion of image activities. Queries primary sources and OIG, as applicable, to verify Provider credentials and qualifications. • Professionally and concisely communicates in writing and by phone, information and/or instructions for updating and correcting databases.
• Resolves 1099 and W9 discrepancies.
• Assist in the development and update of protocols and procedures.
• Coordinates with Claims and other departments on Provider database related issues.
• Resolves daily error reports which include data rejected from claims system including data rejecting from all downstream systems.
• Performs other duties as assigned.
• Regular and reliable attendance is required.


Competencies

Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapts to unique styles; listens critically; collaborates.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach.

High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Technical Skills: Proficient with key databases, including Claims System, Medical Management System, Authorization/Referral Systems, and Provider Information Management System(s); working knowledge of claims reimbursement methodology and medical coding; healthcare or managed care experience


Working Conditions

Working Conditions:

• Availability to cover any work shift
• Works within a standard office environment, with minimal travel
• Extensive computer work with prolonged periods of sitting


Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?


Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.


DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.


Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

TriWest job postings typically include a salary range, which can vary based on the specific role and location , but generally this position ranges from around $41,000 to $44,000 per year.


Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.