Associate Provider File Representative

Job ID: J117349
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Feb 14, 2018

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Description

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.  The incumbent ensures compliance with BCBS and CMS requirements, DOH regulations, internal, private business and governmental audits. The incumbent reviews and processes 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.  
  • Maintain and initial setup of assignment accounts (AA) from the AA applications.
  • Update group and provider affiliations from AFBs and written requests.
  • Maintain accurate data of1099 tax ID updates.
  • Maintain accurate data of UPIN/PTAN and/or Medicare Welcome Letter information.
  • Maintain accurate data of state license updates.
  • Maintain accurate data of Enumerating providers.
  • Maintain accurate data of name changes, demographic data updates, specialty changes.
  • Maintain accurate data of hospital affiliations, network affiliations, network terminations.
  •  Maintain accurate data of facility Agreement data, Institutional non-contracted files. 
  • 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.
  • 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.
  • Responsible to educate providers for obtaining and updating provider identifiers. 
  • Other duties as assigned or requested.

EDUCATION

Required

  • High School Diploma or GED

Substitutions

  • None

Preferred

  • None

EXPERIENCE

Required

  • 0 - 2 years of experience in Provider Data Management, Credentialing, Customer Services or Claims. 

Preferred

  • None

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • None

    

SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?          

No


WORK ENVIRONMENT
Is Travel Required?
No
 

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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