1101 Vermont Ave NW
Suite 1200
Washington, DC 20005

Kids Are Our Everything.
Department
10521 HSCSN - Provider Affairs
Pay Range
$54,683.20 - $91,145.60
The Provider Data Specialist is responsible for the management of the HSCSN Network provider data. This includes the capture and processing of provider demographic information related to the HSCSN Network Providers within health plan systems (i.e., credentialing, claims, utilization management, and care management systems), management of the online and published provider directories as well as the ongoing monitoring/ quality review process. The Provider Data Specialist employs an analytical approach for quality assurance, drives business requirements towards opportunities to automate, leads the audit process of provider network data, and ensures the timely upload of provider data relative to new HSCSN provider contracts as well as changes to existing provider contracts and panels.
Minimum EducationHigh School Diploma or GED (Required)
Bachelor's Degree Business, Health Care Management, Health Care Administration, or Information Technology (Preferred)
Minimum Work Experience3 years 1. A minimum of three (3) years prior experience working with managed care and/or health care setting. (Required)
1 year 2. Prior experience in working with provider and health plan data sets required.
3. Knowledge of claims, network development, provider network operations, provider relationship management, and provider demographic data sets and identifiers, required.
4. Knowledge of Medicaid and other State and Federal mechanisms, i.e., claims processing, UM programs, provider contract administration, NCQA, HEDIS, required.
5. Excellent public presentation, negotiation, stakeholder facilitation, time management, problem solving, analytical, organizational, written, and verbal skills are essential.
(Required)
1 year 6. General knowledge of legislative and government activities and marketplace issues affecting the region, preferred.
7. Experience with developing and implementing provider data quality processes, highly preferred.
8. Medium to high-level proficiency in Microsoft Word, Excel, Access, and Visio, required. SQL, high desirable
(Preferred)
Job Functions- 1. Manages the provider add/change process and ensures the timely update and entry of provider demographic data within core health plan systems (i.e., QNXT claims systems, Guiding Care utilization management and CM systems). Adheres to system requirements an