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:
  • 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.

• 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.

Minimum

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

Language (Other than English): None

Travel Requirement: 0% - 25%

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