Provider Data Specialist_NO

Provider Data Specialist Who are we? Versant Health is one of the nation’s leading administrators of managed vision care, serving millions of our clients’ members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision. As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, and no‑cost‑to‑you vision insurance for you and your qualified dependents. We are also invested in your success, with many opportunities for advancement and development throughout all stages of your career. See how you can make a difference with the support of strong leadership and a team environment. See Everything, Be Anything™. What are we looking for? The Provider Data Specialist role is responsible for educating, verifying, monitoring, and accurately managing all of Versant Health’s two national networks of 80,000+ ophthalmology and optometric practitioner and office demographic and payee data. The role performs additions, changes, and terminations to Versant Health’s provider data systems to positively affect the accuracy of the provider directory, utilization management and authorizations, and claims processing. The Provider Data Specialist also performs periodic audits, maintenance, and troubleshooting of provider, office, and payee data utilizing the National Practitioner Identifier (NPI) Registry, state provider master files for Medicaid registration, and tax identification programs. Where you will have an impact Directly responsible for creating newly contracted providers, their offices, and payees in the three provider databases based on data received via contracting, credentialing reports, and direct provider submissions. Directly responsible for creating new non‑contracted providers, their offices, and payees in the three provider databases; comprehensively reviews and edits existing non‑contracted provider data to facilitate accurate claims processing and the issuance of authorizations. Comprehensively review, edit, and update existing provider, office, and payee records as needed and as requested, acting on requests from internal and external customers. Terminate provider, office, and payee records as requested, using correct termination reason codes and reviewing documentation to determine controllable and non‑controllable terminations. Manage complex retailer and provider group data by periodically reviewing provider databases and rosters, performing updates to the three provider databases. Manage the “Provider Pick” and “Provider Contract” claims pending queue and provide guidance to claims on processing. Maintain IRS standards for payees and utilize tax identification number verifications. Annually resolve all 1099‑B submissions to Versant Health. Support the Accounts Receivable Department with provider education on negative balance accounts and network suspension and reactivation. Educate and assist providers and their office personnel with understanding the uses, importance, and impact of their provider data. Educate and assist all Versant Health departments with provider data, provider directory questions, and various data integrity projects. Review and process provider directory data updates from contracted vendor out‑reach teams to ensure data accuracy; perform updates, corrections, and terminations of provider and office data. Contact assigned providers to validate required data elements via phone and/or email. Conduct peer‑review audits, provide feedback to reduce errors and improve processes, and maintain current provider data to ensure network quality. May represent the provider network area on department‑related IT projects. What’s necessary to do the job? Four to five years of experience with a managed care organization in provider data management, credentialing, network management, development, and/or provider relations. Combination of education and work experience required; associate or bachelor’s degree preferred. Capable and comfortable handling PHI, PII, sensitive and confidential information with discretion and trust. Experience includes direct responsibility for managing provider, office, and payee data and/or claims processing. Experience working with provider networks and healthcare providers. Knowledge of CMS Provider Directory regulations. Proficiency in Microsoft Office (Excel, Word, Access, PowerPoint). HIPAA & Security Requirements All associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI). Associates may have access to covered information, cardholder data or other confidential customer information that must be protected at all times. Associates must adhere to all data security guidelines established within the company’s Privacy & Security Training Program. Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process. Versant Health is a proud Equal Employment Opportunity and affirmative action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law. The wage range for applicants for this position is $20.00 to $21.50. All incentives and benefits are subject to the applicable plan terms. #J-18808-Ljbffr Versant Health