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TriWest Healthcare Alliance · 20 hours ago

Provider Data Resolution Specialist

United States

Full-time

Remote

Entry Level

$41K/yr - $53K/yr

2+ years exp

TriWest Healthcare Alliance is dedicated to serving the healthcare needs of America's heroes. The Provider Data Resolution Specialist ensures the accurate maintenance and synchronization of critical provider data across various systems while communicating with internal and external customers to resolve discrepancies and maintain compliance with provider contracts.

Health Care

No H1B

Security Clearance Required

U.S. Citizen Only

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

Qualification

Provider Data Management SystemClaims SystemAuthorization/Referral SystemHealth Care experienceMicrosoft SuiteComputer LiteracyCoping / FlexibilityCommitment to TaskHigh Intensity EnvironmentCommunication skillsOrganizational skillsProblem Solving