Provider Data Resolution Spec

Summary

TriWest Healthcare Alliance connects America’s heroes with health care in the community. The Provider Data Resolution Specialist maintains and synchronizes Provider data across claims, authorization, referral, and credentialing systems, resolves data and reimbursement discrepancies, and communicates with providers and internal teams to ensure accurate downstream processing.

Responsibilities

• Resolves Provider data discrepancies related to claims processing, including contract reimbursement rates within the allotted timeframe
• Manages daily follow up of Provider data correction requests and issues to ensure databases are current and accurate
• Ensures and maintains accurate data within the Provider Claims and Authorization databases
• Contacts providers to verify all credentialing, claims, and billing information
• Ensures appropriate tax documentation is obtained and imaged for Provider files
• Corrects reimbursement issues within claims payment system
• Develops, maintains, and processes reimbursement terms ensuring correct claims payment and downstream processing
• Reviews Provider contract language and identifies when a contract is out of compliance. Processes Provider contracts, run reports, and responds to inquiries regarding contract compliance issues; images and indexes contracts and return images to network subcontractors; conducts quality assurance activities to ensure image quality and completion of image activities. Queries primary sources and OIG, as applicable, to verify Provider credentials and qualifications
• Professionally and concisely communicates in writing and by phone, information and/or instructions for updating and correcting databases
• Resolves 1099 and W9 discrepancies
• Assist in the development and update of protocols and procedures
• Coordinates with Claims and other departments on Provider database related issues
• Resolves daily error reports which include data rejected from claims system including data rejecting from all downstream systems
• Performs other duties as assigned
• Regular and reliable attendance is required

Skills

• Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position
• • High School Diploma or GED
• • If supporting TRICARE contract, must be a U.S. Citizen
• • If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DOD) background adjudication
• • 2 years of varied responsible experience with computer database programs
• • 2 years of Health Care experience such as claims, provider data or authorization or referral processing
• • Experience with Microsoft Suite (including, but not limited to, Word, Excel and Outlook)
• • Availability to cover any work shift
• • Works within a standard office environment, with minimal travel
• • Extensive computer work with prolonged periods of sitting
• Ability to conform to established policies and procedures; exhibit high motivation
• Ability to influence or persuade others under positive or negative circumstances; adapts to unique styles; listens critically; collaborates
• Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications
• Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach
• Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow
• Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented
• Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues
• Proficient with key databases, including Claims System, Medical Management System, Authorization/Referral Systems, and Provider Information Management System(s); working knowledge of claims reimbursement methodology and medical coding; healthcare or managed care experience
• • 1+ years of Health care claims resolution experience
• • Experience using a Provider Data Management System, Claims System, or Authorization/Referral system

Qualifications

Must Haves

• Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position
• • High School Diploma or GED
• • If supporting TRICARE contract, must be a U.S. Citizen
• • If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DOD) background adjudication
• • 2 years of varied responsible experience with computer database programs
• • 2 years of Health Care experience such as claims, provider data or authorization or referral processing
• • Experience with Microsoft Suite (including, but not limited to, Word, Excel and Outlook)
• • Availability to cover any work shift
• • Works within a standard office environment, with minimal travel
• • Extensive computer work with prolonged periods of sitting
• Ability to conform to established policies and procedures; exhibit high motivation
• Ability to influence or persuade others under positive or negative circumstances; adapts to unique styles; listens critically; collaborates
• Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications
• Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach
• Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow
• Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented
• Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues
• Proficient with key databases, including Claims System, Medical Management System, Authorization/Referral Systems, and Provider Information Management System(s); working knowledge of claims reimbursement methodology and medical coding; healthcare or managed care experience

Nice to Haves

• • 1+ years of Health care claims resolution experience
• • Experience using a Provider Data Management System, Claims System, or Authorization/Referral system

Benefits

• Remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).
• Frequent pay raises
• Overtime opportunities to earn even more
• Recognition and reward programs
• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time