Associate Provider File Representative

Overview

Company : Highmark Inc.

Job 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. 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.

• Maintaining and initial setup of assignment accounts (AA) from the AA applications
• Updating group and provider affiliations from AFBs and written requests
• 1099 tax
• 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

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

Education

Required

• High School Diploma or GED

Substitutions

• None

Preferred

• None

Experience

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

Licenses or Certifications

Required

• None

Preferred

• None

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

Language (Other than English) None

Travel Requirements None

Position Type Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Occasionally

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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with HIPAA and related privacy policies and procedures and with the company’s Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct, including adherence to applicable federal and state laws, rules, and regulations as well…