Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Under direct supervision, performs typically routine initial and ongoing practitioner, provider, and organization data entry and credentialing into the various modules of the Provider Data Management System. Supports compliance with standards set by individual states, federal and accrediting organizations and meets production and quality metrics.
This position has the option to work remote; Ohio residents preferred.
Responsibilities
Provider Credentialing & Data Specialist I
- Categorizes returned mail and determines action needed based on type of correspondence. Contacts providers and/or internal departments by phone or electronically when data is incomplete or incorrect. Works with internal staff members, provider office staff, and/or other health related entities to obtain additional information.
- Retrieves applications and/or data from central repositories for provider data. Accesses various external websites, internal matrices, and contacts organizations to verify accuracy of information provided. Enters verified data into the Provider Data Management Systems.
- Acts as a primary source to verify limited provider information to support performance guarantees.
- Generates reports from system for prioritization of work queue.
- Supports special projects as needed.
- Performs other duties as assigned.
Provider Credentialing & Data Specialist II
- Retrieves applications and/or data from central repositories for provider data. Accesses various external websites, internal matrices, and contacts organizations to verify accuracy of information provided. Identifies whether application and/or document is clean or requires further review and routes to appropriate area. Enters verified data into the Provider Data Management Systems. Identifies eligibility for networks and updates appropriately affecting the accuracy of claim payments and the provider directory.
- Electronically contacts providers and/or internal departments when data is incomplete. Works with internal staff members, provider office staff, academic entities and/or other health related entities to verify the accuracy of the information provided.
- Generates reports from system for prioritization of work queue.
- Evaluates and researches practitioners that do not meet network participation criteria or are found to have on-going sanction monitoring issues. Gathers and summarizes information for Credentialing Committee or Provider Contracting and responds to questions as needed.
- Researches questions for accreditation or regulatory audits.
- Supports special projects as needed
- Performs other duties as assigned.
Senior Provider Credentialing & Data Specialist
- Retrieves applications and/or data from central repositories for provider data. Accesses various external websites, internal matrices, and contacts organizations to verify accuracy of information provided. Identifies whether application and/or document is clean or requires further review and routes to appropriate area. Enters verified data into the Provider Data Management Systems. Updates rates in Provider Data Management Systems affecting the accuracy of claim payments. Identifies eligibility for networks and updates appropriately affecting the accuracy of claim payments and the provider directory.
- Electronically contacts providers and/or internal departments when data is incomplete. Works with internal staff members, provider office staff, academic entities and/or other health related entities to obtain verify the accuracy of the information provided.
- Documents and summarizes complex issues found in review to Credentialing Committee or Provider Contracting and responds to questions. May attend Committee meetings to respond to questions and record meeting minutes.
- Generates reports from system for prioritization of work queue.
- Evaluates and researches practitioners that do not meet network participation criteria or are found to have on-going sanction monitoring issues. Gathers and summarizes information for Credentialing Committee or Provider Contracting and responds to questions as needed.
- Researches and responds to questions for accreditation or regulatory audits.
- Supports special projects as needed.
- Orients, trains, and assists more junior level staff.
- Performs other duties as assigned.
Qualifications
Provider Credentialing & Data Specialist I
Education and Experience
- Associate degree in business or healthcare administration or related field, or equivalent combination of education/training and experience.
- 1 year of experience in a health plan, medical office, hospital, or similar administration.
Technical Skills and Knowledge
- Basic to intermediate Microsoft Office (Word, Excel) and internet navigation skills.
- Basic knowledge of terminology used in a healthcare administration setting.
- Strong data entry skills.
Provider Credentialing & Data Specialist II
Education and Experience
- Associate degree in business or healthcare administration or related field, or equivalent combination of education/training and experience.
- 1 year of experience as a Provider Credentialing & Data Specialist or equivalent experience in a health plan, medical office, hospital, or similar administration.
Professional Certification(s):
- CPCS preferred but not required.
Technical Skills and Knowledge
- Intermediate Microsoft Office (Word, Excel), database reporting, OnBase (document management system), and internet navigation skills.
- Knowledge of provider credentialing and/or database management procedures.
- Strong data entry skills.
Senior Provider Credentialing & Data Specialist
Education and Experience
- Associate degree in business or healthcare administration or related field, or equivalent combination of education/training and experience.
- 2 years progressive experience as a Provider Credentialing & Data Specialist or equivalent experience in a health plan, medical office, hospital, or similar administration.
Professional Certification(s):
- CPCS or CPMSM preferred but not required.
Technical Skills and Knowledge
- Intermediate to advanced Microsoft Office (Word, Excel), database reporting, OnBase (document management system), and internet navigation skills.
- Advanced knowledge of provider credentialing and/or database management procedures.
- Strong data entry skills.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
- Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
- On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
- Discounts at many places in and around town, just for being a Medical Mutual team member.
- The opportunity to earn cash rewards for shopping with our customers.
- Business casual attire, including jeans.
Excellent Benefits and Compensation:
- Employee bonus program.
- 401(k) with company match up to 4% and an additional company contribution.
- Health Savings Account with a company matching contribution.
- Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
- Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
- Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
- After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
- Career development programs and classes.
- Mentoring and coaching to help you advance in your career.
- Tuition reimbursement up to $5,250 per year, the IRS maximum.
- Diverse, inclusive and welcoming culture with Business Resource Groups.
About Medical Mutual:
Medical Mutual’s status as a mutual company means we are owned by our policyholders, not stockholders, so we don’t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There’s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We’re not just one of the largest health insurance companies based in Ohio, we’re also the longest running. Founded in 1934, we’re proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.