Provider Data Management Resolution Analyst
- Reno, NV
- Permanent
- Full-time
- Manages and clearly responds to providers, their liaisons, leadership, doctors, and internal inquiries via provider web portals shared mailboxes, provider data management, credentialing and contracting shared mailboxes.
- Manages service ticket requests submitted to LaserFiche for resolution, following up to ensure timely closure.
- Responsible for monitoring and coordinating the completion of Health Plan practitioner and allied health professionals credentialing applications.
- Manages information and updates to appropriate issue tracking logs (SmartSheet) to ensure incoming complaints/requests are tracked, closed, and monitored for past due issues.
- Creates weekly Provider Compliant Report for Commercial and MA, as well as any new reports to satisfy regulatory compliance or departmental needs.
- Supports Provider Relations Representatives to resolve questions, and escalated calls.
- Maintains data integrity of all credentialing software programs through accurate and timely data entry
- Works collaboratively with Customer Services Resolution Specialist and Claims Resolution Specialist to resolve provider claims processing disputes.
- Promotes world class customer service for internal and external customers.
- Report escalated issues that need further evaluation to the Director, Operations.
- Analyzes trends, identifies problems, and issues and brings forth proposed resolutions including provider training.
- Reports provider issues to assigned Provider Relations Representative.
- Consistently demonstrates and maintains appropriate effective professional communications with internal department, providers and provides timely follow up as needed.
- Enters, updates, and maintains data from provider applications into claims processing databases, focusing on accuracy, and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures
- Communicates clearly with providers, their liaisons, leadership, and doctors, as needed to provide timely responses upon request on day-to-day credentialing and claims issues as they arise.
- Monitor expiring licensure, board, and professional certifications and other expirable documents with practitioners within the prescribed timeframe.
- Communicate with provider, practice manager or contract signatory to receive active current licensure for providers unable to verify via credentialing platform.
- Initiate provider terminations for credentialing non-compliance.
- Actively participate in team meetings and process improvement initiatives to continuously improve work efficiency.
- Coordinates timely collection and integration of selected performance monitoring activities and follows up as needed (i.e., office visit requests, member complaint reports, quality improvement activity reports, etc.).
- Process all provider and group terminations within departmental turnaround guidelines
- Support LaserFiche application and workflow and provide insight to process improvement and efficiencies.
- Support network management with day-to-day operations, identify areas for improvement related to internal and external provider operations.
- Performs special projects as assigned by the management.
- Loan Forgiveness Program
- Challenging and rewarding work environment
- Competitive Compensation & Generous Paid Time Off
- Excellent Medical, Dental, Vision and Prescription Drug Plans
- 401(K) with company match and discounted stock plan
- SoFi Student Loan Refinancing Program
- Career development opportunities within UHS and its 300+ Subsidiaries! · More information is available on our Benefits Guest Website: benefits.uhsguest.com
QualificationsQualifications and Requirements:
- High school diploma: Associates degree or equivalent work experience preferred
- Minimum of 6 months experience in working with provider data and credentialing functions
- 3 years customer service with ability to handle challenging customer situations in a professional manner.
- Knowledge of QNXT claims processing system
- Knowledge of Provider and Credentialing terminology
- Ability to interpret health plan benefits and provider contracts.
- Excellent computer skills which must include proficiency in Microsoft Office Suite with emphasis on Excel and Power Point.
- Excellent English communication skills with an ability to communicate complex program criteria into easily understood summaries both orally and written
- Proficient critical-thinking and analytical problem-solving skills
- Identify, recommend, and implement processes that improve quality, increases productivity, reduces waste, costs, and rework resulting in business improvement and customer satisfaction.
- Ability to interpret and apply established policies and procedures.
- Must be a team player and ability to work independently with little supervision