Associate Provider File Representative

Job Summary

This job is responsible for corporate provider enrollment and provider file maintenance across all markets. This includes enrollment, contracting, and demographic provider information. Incumbent ensures compliance with BCBS and CMS requirements, DOH regulations, internal, private business, and governmental audits. Responsible for reviewing and processing additions, updates, and deletions of provider information in the Provider File database. Ensures executions of data entry and updates are completed in a timely and accurate manner.

Essential Responsibilities

Maintain accurate data in provider file data systems. Common transactions include:

Maintaining and initial setup of assignment accounts (AA) from the AA applications

Updating group and provider affiliations from AFBs and written requests

1099 tax ID updates

UPIN/PTAN and/or Medicare Welcome Letter information

State license update

Enumerating providers

Name changes, demographic data updates, specialty changes

Hospital affiliations, network affiliations, network terminations

Facility Agreement data, Institutional non-contracted files

File Maintenance Analysis.

Applying complex and detailed guidelines in the review process of the submitted requests

The documentation application must comply with BCBS, DOH, CMS, MSBCBS, and Highmark requirements.

Routinely contact external sources such as the Provider offices, state licensing agencies, and provider reps to collect or clarify information or documentation, which in turn must be reviewed and evaluated against the established guidelines

Ensure the file meets all regulations prior to updating the provider file

Data Integrity. Contact external sources to collect or clarify information or documentation which in turn must be reviewed and evaluated against the established guidelines and procedures to ensure the file meets all policy and procedures in conjunction with regulations. Maintain and update internally required data elements which include but are not limited to:

Assigned Blue Shield provider numbers

National Provider Identifier (NPI)

CMS required provider identifiers for compliance with corporate and federal contracts.

This individual will be also responsible to educate providers for obtaining and updating provider identifiers.

Other duties as assigned or requested.

Education

Required: High School Diploma or GED

Experience

One year of experience in Provider Data Management, Credentialing, Customer Services, or Claims.

Skills

Ability to communicate with both providers and customers, Microsoft Office, Typing/Computer Proficiency, Problem Solving Skills

Pay Range

Minimum: $19.27 Maximum: $27.42