Provider Network Configuration Specialist

Job Description

Job Description

POSITION SUMMARY

The Network Data Specialist II is responsible for advanced management, analysis, configuration, and validation of provider data across enterprise provider, claims, and network management systems. This role ensures the accuracy, integrity, and operational readiness of complex provider data configurations that support claims adjudication, network operations, regulatory compliance, and business reporting.

The Network Data Specialist II serves as a subject matter resource for provider data processes, independently manages complex data activities, identifies opportunities for process improvements, and collaborates with Provider Relations, Credentialing, Claims, Network Operations, and IT teams to resolve data issues and enhance system performance.

ESSENTIAL DUTIES & RESPONSIBILITIES

· Load contracted (participating) providers into provider and claims systems in accordance with executed provider agreements and configuration requirements.

· Load and maintain non-participating provider records to ensure accurate claims processing and pricing.

· Maintain accurate, complete, and up-to-date provider data across all claims and provider databases.

Provider Data Management

Ensure integrity of critical provider information including:

· Provider demographics

· Tax ID and billing information

· Specialty and taxonomy codes

· Network participation status

· Contract effective dates and terms

· Validate provider data accuracy prior to system loading and ongoing updates.

· Apply advanced business rules and system requirements to ensure accurate provider setup across downstream applications.

· Identify data trends, recurring issues, and opportunities to improve provider data accuracy and operational efficiency.

System Maintenance & Data Synchronization

· Perform advanced provider data synchronization across multiple claims, provider, and configuration platforms.

· Analyze discrepancies between systems and source documentation and coordinate corrective actions.

· Ensure consistency of provider information across enterprise platforms.

· Identify and resolve data discrepancies between systems and source documentation.

· Support updates to provider files based on contracting, credentialing, or network changes.

Provider Relations & Credentialing Collaboration

· Partner with Provider Relations, Credentialing, Claims, and Network Operations teams to resolve complex provider data issues..

· Work closely with Credentialing teams to ensure only appropriately credentialed providers are loaded and active in systems.

· Validate credentialing status and ensure alignment with network participation requirements prior to system activation.

· Support resolution of provider data issues identified by internal stakeholders or external providers.

· Provide recommendations regarding provider data processes, workflows, and configuration improvements.

Non-Participating Provider Configuration

· Manage complex non-participating provider configurations to support accurate claims routing, pricing logic, and out-of-network processing.

· Ensure non-participating provider data supports correct claims adjudication and out-of-network processing rules.

· Maintain accurate classification of provider participation status across systems.

Provider Rosters & Reporting

· Manage monthly provider roster updates, including additions, terminations, and changes.

· Reconcile provider rosters received from external sources against internal systems.

· Validate and distribute provider roster files to appropriate internal stakeholders.

· Support reporting needs related to provider network composition and data accuracy.

· Identify trends and recommend improvements related to provider data management.

Quality Assurance & Compliance

· Validate provider data against contractual requirements, network standards, and system specifications.

· Ensure compliance with internal policies and regulatory requirements related to provider data management.

· Maintain audit-ready documentation of provider data changes and updates.

Support internal and external audits by providing accurate documentation and detailed data analysis.

SUPERVISORY RESPONSIBILITY

· No.

QUALIFICATIONS & EDUCATION

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Minimum Qualifications

· High School Diploma or GED required.

· Minimum of 3 years of experience in healthcare provider data management, claims systems, credentialing support, or managed care operations.

· Experience working with provider databases, claims systems, or network configuration tools.

· Equivalent combination of education and experience may be considered.

· Strong analytical skills with the ability to identify issues, analyze root causes, and implement solutions.

· advanced proficiency with Microsoft Excel and data analysis tools.

· Strong communication skills with the ability to collaborate across multiple business functions.

Preferred Qualifications

· Experience in managed care health plan or health insurance environment.

· Familiarity with provider credentialing and contracting processes.

· Understanding of provider taxonomy, NPI, and healthcare provider identifiers.

· Experience managing provider rosters or large-scale data files.

· Knowledge of claims adjudication systems and network configuration rules.

· Experience mentoring team members or serving as a subject matter expert.

Skills & Competencies

· Strong attention to detail and data accuracy

· Ability to manage large volumes of provider data efficiently

· Strong analytical and problem-solving skills

· Understanding of healthcare provider data structures and systems

· Ability to collaborate effectively with cross-functional teams

· Strong organizational and time management skills

· Ability to work independently in a production-driven environment

Additional Notes

The Network Data Specialist plays a critical role in ensuring the accuracy and integrity of provider data across the health plan’s systems. This position directly impacts claims accuracy, provider payment

integrity, and network operations by ensuring providers are correctly loaded, maintained, and aligned with contractual and credentialing requirements.