Provider File Representative Senior

Job ID: J118695
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

I.    GENERAL OVERVIEW:  
This position 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.


II.    ESSENTIAL RESPONSIBILITIES:  
1.    Maintain accurate data in provider file data systems.  Common transactions include: 

  o    Maintaining and initial setup of assignment accounts (AA) from the AA applications
  o    Updating group and provider affiliations from AFBs and written requests
  o    1099 tax ID updates
  o    UPIN/PTAN and/or Medicare Welcome Letter information
  o    State license update
  o    Enumerating providers
  o    Name changes, demographic data updates, specialty changes
  o    Hospital affiliations, network affiliations, network terminations
  o    Facility Agreement data, Institutional non-contracted files. 
2.    File Maintenance Analysis.  
  o    Applying complex and detailed guidelines in the review process of the submitted requests
  o    The documentation application must comply with BCBS, DOH, CMS, MSBCBS and Highmark requirements.  
  o    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
  o    Ensure the file meets all regulations prior to updating the provider file
3.    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: 
  o    Assigned Blue Shield provider numbers
  o    National  Provider Identifier (NPI)
  o    CMS required provider identifiers for compliance with corporate and federal contracts.
  o    This individual will be also responsible to educate providers for obtaining and updating provider identifiers. 
8.    Other duties as assigned or requested.


III. QUALIFICATIONS:
Education, Licenses/Certifications, and Experience 
Minimum

High School Diploma or GED

5-10 years of related, progressive experience


IV. SCOPE OF RESPONSIBILITY  
Does this role supervise/manage other employees?   No  

V. WORK ENVIRONMENT

Is travel required?

No 

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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