Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

Under direction of the Provider Information Supervisor, the Provider Information Specialist processes, maintains, and revises all components of the provider information database for all THP products/plans. The candidate is responsible for the integrity of all practitioner information housed in THP provider data systems (i.e. TAHPMASTER, DIAMOND, CACTUS, ALUI, XPRESS and HRP) and communicates with both internal and external customers by telephone, email and facsimile and in writing regarding practitioner information. The Specialist has comprehensive knowledge of IPA (Independent Practitioners Affiliations) and ACO (Accountable Care Organizations) specifics and is in contact with their counterpart regarding individual providers as well as changes within the IPA /ACO organization, working closely with the Contract Administrator to keep our provider network current. The Specialist also has knowledge regarding contracts and tax id forms, and many other supporting documents, as well as claims payment and claims forms and is a resource externally for providers and internally for numerous departments such as claims, member services, provider services, network contracting, allied health, and others.

The department is the business owner of THP's provider network data systems and the candidate must be knowledgeable and familiar with the data content to ensure accurate entry. Data integrity is critical to ensure efficient claims processing, creation of accurate provider directories and mailings, and reliability of customer servicing information. Must have the ability to resolve complex issues independently and bring issues to a satisfactory resolution.

The Provider Information Specialist provides customer service to IPA/ACO contacts, doctors, and other providers, billing services and, internally, provides customer service and direction to claims operations, provider services, allied health services, credentialing and contracting.

Job Description

Responsible for assessment, validation and collection of appropriate contract and supporting documents prior to adding or modifying provider data. Responsible for the execution of consistent, quality data input of provider information through discussion and discovery with providers and their contacts prior entering data into THP's complex data systems (TAHP, DIAMOND, CACTUS, ALUI, XPRESS, HRP).

Elements requiring documentation for additions and modifications e.g., demographic information , provider payment information including group affiliation; provider terminations and provider category changes.

Data entry of the elements as indicated above. Responsible for maintaining various reporting tools and quality metrics for tracking provider information changes, including, but not limited to the practitioner change reports for Commercial and Medicare Preferred.

Communicate and confirm provider information changes to individual provider and designated internal departments (e.g., Provider Services, Enrollment, Claims, NCPM)

Works with providers, directly and through other internal departments, to resolve conflicts over provider status and other issues. Evaluate and assess correspondence directly from providers and/or internal departments regarding provider status or changes and maintain multiple databases as necessary. Responsible for resolving tax identification issues for providers identified by the Internal Revenue Service. Verify data is correct and complete in provider files for newly credentialed practitioners, and other providers including ancillary providers and/or ancillary facilities.

Ensure the adequacy and reliability of all necessary provider information

On a daily basis, resolve and document issues requested via MACESS in a timely manner, consistent with established department standards

In coordination with the Provider Information Supervisor, initiate, coordinate, and execute special projects relating to enhancements for system changes and provider information to improve the quality of provider data as it relates to plan operations.

Requirements

EDUCATION: (Minimum educations & certifications required)

B.A./B.S. or equivalent in health care or related field preferred.

EXPERIENCE: (Years of experience)

Academic concentration in health care field or 1-2 years experience in health care field. Experience with personal computer required. Experience in database management systems preferred. Knowledge of Windows, Microsoft Word, Excel preferred.

SKILL REQUIREMENTS: (Include interpersonal skills)

Must have the ability to maintain and manipulate a complex provider database. Must be able to prioritize multiple tasks and achieve deadlines. Must have ability to adapt to a changing environment. The position requires the ability to analyze and understand complex payment issues and plan operational concerns. Strong written and verbal skills are necessary. Individual must possess initiative, judgment, exceptional organizational skills as well as a keen attention to detail.

Must be able to work cooperatively as a team member.

Frequent contact, both written and verbal, with practitioners, office staff, billing agents and internal customers. Must use discretion when dealing with plan providers and all other departments.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)

Fast paced office environment handling multiple demands. Must be able to exercise appropriate judgment as necessary. Requires the ability to use PC. Ability to transfer information from paper-form to on-line data is necessary. In the absence of specific direction, must be able to prioritize workload. Work requires ability to use independent judgment and discretion in decision-making. At the home office, work is done in a cubicle area with other employees. Specialist must be able to differentiate between colors in order to manage the complex filing system.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

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