Typical Duties

• Maintains provider data though rosters and Share Point.
• Processes Medicaid and Medicare rosters from provider and facilities.
• Processes contracts via JIRA for mapping and pricing.
• Distinguishes between contract labels and rates Medicaid, Medicare, and Exchange.
• Produces and audits provider directories for multiple medical groups adding terming locations.
• Identifies discrepancies with practitioner data and information.
• Maintains medical group demographic information using Vida Pro, NPESS and IObserver.
• Calls credentialing departments to verify provider information such as specialty and service location information.
• Verifies if provider is active or terminated on state file. Produces member move forms when providers term affiliation before the end of each month.
• Sends weekly data information to Claim Payers accordingly.
• Reviews and audits provider directories.
• Audits and configures new and existing provider/hospital/ancillary contracts supporting Health Plan Services.
• Maintains existing provider/hospital/ancillary demographic information ensuring provider data is maintained according to contractual requirements.
• Reviews provider applications, applies policy and criteria, processes files through and forward to appropriate area for systems loading.
• Ensures that all provider contract data is accurate and complete to facilitate the data upload of supporting contractual reimbursement expectations.
• Validates participation in the State's Medical Assistance Program for new and existing providers.
• Creates reports and conducts data analysis.
• Manages distribution of internal reports related to network.
• Remains current with contract updates and explains contractual relationships as needed.
• Provides training, mentoring and guidance to new staff members.
• Completes special projects as assigned or directed.
• Performs other duties as assigned