Provider Data Specialist

Provider Data Specialist

The Provider Data Specialist is responsible for the accurate maintenance, validation, and integrity of provider and facility data within the Uniformed Services Family Health Plan (USFHP) network. This role supports provider network operations by ensuring compliance with regulatory requirements, health plan standards, credentialing activities, claims processing, directory accuracy, and member access initiatives. The Provider Data Specialist collaborates closely with Provider Relations, Credentialing, Contracting, Claims, Member Services, and Compliance teams to maintain high-quality provider data and support exceptional service to members, providers, and military beneficiary families.

Key responsibilities include:

• Maintain provider demographic, contractual, credentialing, and practice location information in provider databases and health plan systems.
• Process provider additions, terminations, changes, and updates accurately and within established service level agreements (SLAs).
• Validate and audit provider records to ensure data completeness, accuracy, and consistency across multiple systems.
• Perform routine data quality reviews and corrective actions to minimize provider data discrepancies.
• Ensure provider data complies with Centers for Medicare & Medicaid Services (CMS), Department of War (DoW), TRICARE, URAC, and USFHP requirements.
• Support provider directory accuracy initiatives and periodic directory validation activities.
• Maintain documentation and audit trails for provider data changes.
• Assist with regulatory audits, corrective action plans, and compliance reporting.
• Coordinate with Provider Relations and Network Management teams regarding provider onboarding, network participation, and demographic updates.
• Support implementation of provider contracts and reimbursement arrangements in provider systems.
• Respond to internal and external inquiries regarding provider data and network status.
• Assist with network adequacy reporting and provider accessibility analyses.
• Partner with Credentialing to ensure provider enrollment and credentialing information is accurately reflected in operational systems.
• Work with Claims Operations to resolve provider-related claims issues resulting from data discrepancies.
• Collaborate with the Contact Center to address provider directory concerns and member access issues.
• Participate in process improvement initiatives focused on data quality and operational efficiency.
• Generate routine and ad hoc reports related to provider data maintenance activities.
• Monitor key performance indicators (KPIs) for provider data accuracy and timeliness.
• Identify trends, root causes, and opportunities for process enhancements.
• Support testing and validation activities for system upgrades and provider data projects.

Required qualifications include:

• Associate degree in Health Information Management, Healthcare Administration, Business Administration, or related field, or equivalent relevant experience.
• 2 or more years of provider data management, provider operations, credentialing support, healthcare administration, or similar experience.
• Experience with Medicare, TRICARE, managed care, or government-sponsored health programs preferred.

Skills and competencies include:

• Advanced Excel skills including pivot tables, VLOOKUP/XLOOKUP, and data validation functions.
• Proficient in Microsoft Office and provider data platforms such as Facets, QNXT, HealthRules, or similar systems.
• Knowledge of provider data management principles, with an understanding of healthcare provider data challenges (directory accuracy, directory maintenance, NPI registries, credentialing, and validation).
• Familiarity with CMS, URAC, NCQA, TRICARE, and healthcare regulatory requirements.
• Experience with CAQH, NPPES, PECOS, and provider credentialing databases.
• Strong attention to detail and commitment to data accuracy, with the ability to analyze complex data and identify discrepancies for regulatory compliance.
• Problem Solving and Critical Thinking

Other requirements include:

• Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.
• Must maintain the confidentiality of protected health information (PHI) and other sensitive data in compliance with HIPAA and BrightonOne policy, and complete required privacy and security training.

This is largely a sedentary role performed in an office setting, requiring extended periods of computer use.

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by federal, state, or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Candidates must be authorized to work in the United States without sponsorship now or in the future.

Salary Description 70,000-80,000 annually