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About the Role

The Provider Data Specialist role is responsible for educating, verifying, monitoring, and accurately managing all of Versant Health’s two national networks of 80,000+ Ophthalmology and Optometric practitioner’s and office’s demographic and payee data. The role performs additions, changes, and terminations to Versant Health’s provider data systems to positively effect the accuracy of the Provider Directory, Utilization Management and authorizations, and claims processing. The Provider Data Specialist role will also perform periodic audits, maintenance, and troubleshooting of provider, office, and payee data utilizing the National Practitioner Identifier (NPI) Registry, state’s Provider Master Files for Medicaid Registration, and Tax Identification programs.

Responsibilities

Create newly contracted providers, their offices, and payee(s) into the three provider databases based on data received via contracting, credentialing reports, and direct provider submissions.
Create new non-contracted providers, their offices, and payee(s) into the three provider databases.
Comprehensively review and edit existing non-contracted provider data to facilitate accurate claims processing and the issuance of authorizations.
Comprehensively review, edit, and update existing provider, office, and payee records as needed and requested, reviewing documentation and reports, and acting on requests from internal and external customers.
Terminate provider, office, and payee records as requested using correct termination reason codes to determine controllable and noncontrollable terminations, requiring extensive review of documentation and reports, and acting on requests from internal and external customers.
Manage complex Retailer and Provider Group data by periodically receiving and comprehensively reviewing provider databases and rosters and performing updates to the three provider databases.
Manage “Provider Pick” and “Provider Contract” claims pend queue and provide guidance to Claims on claims processing.
Maintain IRS standards for Payees and utilize Tax Identification Number verifications.
Annually resolve all 1099-B submissions to Versant Health.
Support Versant Health Accounts Receivable Department with provider education on Negative Balance accounts and network suspension and reactivations.
Educate and assist Providers and their office personnel with understanding the uses, importance, and impact of their provider data to Members and the Provider Directory.
Educate and assist all Versant Health departments with provider data, Provider Directory questions, and various data integrity projects.
Review and process Provider Directory data updates received from contracted Provider Directory & Outreach vendors to ensure data accuracy; perform updates, corrections, and terminations of provider and office data.
Initiate and/or support provider database improvements and communication processes as needed with other departments regarding database enhancements.
Contact assigned providers to validate required data elements via phone and/or email.
Conduct peer review audits and provide feedback to reduce errors and improve processes and performance, maintaining current provider data to ensure the quality of the network, and may be responsible for representing the provider network area on department related IT projects.

Requirements

Four to Five (4-5) years of experience with a managed care organization in a Provider Data Management, Credentialing, Network Management, Network Development, and/or Provider Relations role.
Combination of education and work experience required; Associate or Bachelor’s degree preferred.
Capable and comfortable dealing with Protected Health Information (PHI), Personal Identifiable Information (PII), sensitive, and confidential information with discretion and trust.
Experience must include direct responsibility for managing provider, office and payee data and/or claims processing.
Experience working with provider networks and healthcare providers.
Knowledge and experience in CMS Provider Directory regulations.
HIPAA & Security Requirements: All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures.
As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times.
Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.
Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process.

Skills

Proficiency in MicroSoft Office Excel, Word, Excel, Access, and Power Point

Experience Level

4-5 years

Education Level

Associate or Bachelor’s degree preferred

Salary/Compensations

$22.50

Benefits

Health and dental insurance
Tuition reimbursement
401(k) with company match
Pet insurance
No-cost-to-you vision insurance for you and your qualified dependents

About the Company

Versant Health is one of the nation’s leading administrators of managed vision care, serving millions of our clients’ members nationwide.
We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision.
See Everything, Be Anything™.

Equal Opportunity

Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce.
All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.