Provider Data Specialist

Qualifications you'll bring:

An associates degree or equivalent combination of education and related experience

The availability to work full-time, virtual within New York State.

Two plus years of experience in health insurance or related office experience.

Detail oriented with excellent data entry skills including a high degree of accuracy.

Excellent computer and database skills including strong knowledge of Microsoft Word and Microsoft Excel.

Previous Credentialing experience preferred. Macess, Facets, and Catus preferred.

Curiosity to foster innovation and pave the way for growth

Humility to play as a team

Commitment to being the difference for our customers in every interaction

Your key responsibilities:

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  Excellent member and provider experience- accurate and timely onboarding/credentialing and maintenance of provider data ensuring timely payment of claims. Provide excellent customer service for all inquiries and requests. Collaborate with the Network Management to ensure a robust provider network so that members needs are met especially in coverage areas with fewer facilities and providers. Continuously monitor providers' performance to ensure quality care for members.

  
  

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  Primarily responsible for provider data entry, management, verification and maintenance of MVPs Provider and Facility Network.

  
  

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  Credential and recredential providers and facilities in accordance with MVP, NCQA, CMS, NYS Department of Health and all other regulatory agency guidelines.

  
  

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  Review and prepare files including clean files, issues, and red flag files for the MVP Credentials Committee.

  
  

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  Prepare letters to providers and facilities for credentialing/recredentialing/registration decisions and updates including non-compliance.

  
  

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  Review and Process Provider and Mid-Level Registrations in accordance with MVP policies and procedures including but not limited to License Verification, DEA review, and regulatory sanction checks.

  
  

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  Research and update provider data elements as identified in provider data clean-up projects.

  
  

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  Perform outreach to providers and facilities for required data as needed.

  
  

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  Maintain all provider and facility data in Macess, Cactus and Facets systems. Validate provider education, licensure, education and training, and perform mandated sanction checks such as Licensure, DEA or CDS Certificate, Board Certification if applicable, Medical or Professional education, Residency and Fellowship Training if applicable, Malpractice Insurance and History, Medicare sanctions and opt outs, Medicaid Management Information System (MMIS), National Practitioner Identification Number (NPI) through NPPES, Social Security Administration Death Master File through the National Technical Information Service (NTIS) database, and Clinical Privileges if applicable.

  
  

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  Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

  
  

Where you'll be:

Virtual within New York State