Provider File Representative Senior

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.

• Maintain accurate data in provider file data systems. Common transactions include:
• Maintain 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
• File Maintenance Analysis
• Applying complex and detailed guidelines in the review process of the submitted requests
• Ensure the documentation complies 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 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 also be responsible to educate providers for obtaining and updating provider identifiers
• Other duties as assigned or requested

Minimum

• High School Diploma or GED
• 5-10 years of related, progressive experience

Language (Other than English): None

Travel Requirement: 0% - 25%

Physical, Mental Demands and Working Conditions

Position Type Office-based

Teaches / trains others regularly

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

Rarely 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

Rarely

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 both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum: $22.71

Pay Range Maximum: $35.88

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