Provider Data Maintenance Specialist

General Purpose of Job:

The Provider Data Maintenance Specialist is responsible for researching and gathering data and converting it into meaningful information/reports/files used by the Driscoll Health Plan in the Provider Contracting, Credentialing and Claims systems.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration as required.

• Maintains utmost level of confidentiality at all times.

• Adheres to DHS/DHP policies and procedures.

• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 

• Ensures the integrity of provider data, including research, data extraction, processing, storage, manipulation, analysis and distribution of Provider Data from Credentialing, Contracting and State and Federal databases.

• Creates Add Files and Change Files ensuring data integrity of all provider data being loaded into DHP contracting, credentialing, claims and authorization systems.

• Provides resolution of all DHP Claims Provider Not Found Queue’s to load required Provider data for adjudication on a Participating or Non-participating basis expeditiously as required to meet state mandated claims turnaround time frames.

• Is a Subject Matter Expert on the State of Texas Master Provider File (MPF) and the NPPES NPI Registry in regards to Provider Data required to load Provider information

• Utilizes DHP CRM to communicate with DHP Departments to provide required provider data to the appropriate department for system load.

• Is a Subject Matter expert on DHP Credentialing and Contracting system’s Provider Data.

• Performs other related work as required.

Education and/or Experience:

Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying. Degree Preferred.

• Typically has 6+ years' experience in Texas Medicaid MCO Provider Data Management.

• Knows fundamental concepts, practices and procedures of particular field of specialization.