American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Kansas, Missouri, Oklahoma, Georgia, Mississippi, Florida, Texas, Utah and Tennessee. For more information, visit AmHealthPlans.com.
JOB SUMMARY:
The Provider Data Specialist ensures all contracted and non-contracted provider demographics and payment methodologies are accurate and current with the plan’s operating systems and verifies the integrity of provider demographic data. This position is also responsible for assisting and supporting reporting functions of provider data to appropriate agencies, committees and management.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:
- Maintain provider demographic information through initial contracting submission, credentialing and paper or electronic updates submitted by providers, customer service representatives, Network Services Department, Claims Department, audits, and other sources
- Reviews data and corrects errors as received
- Keep current on all information received; remain within departmental standards
- Download provider credentialing (CAQH) applications; confirm accuracy
- Extract and report data for analyses
- Represent the provider network department on company IT projects such as reporting and tracking provider calls and complaints, or for the support, coordination, and production of the provider directory
- Develop and maintain standards for database integrity and quality assurance, coordinate corrective actions to clean database
- Contact providers in a timely manner to obtain missing and/or incorrect documentation; follow up as necessary
- Participate on calls with network services staff to assist with troubleshooting; recommend enhancements to related programs
- Assist with the preparation of agendas; organize handouts and other materials; take minutes during Credentialing Committee meetings
- Assist with the facilitation of the Credentialing Committee approval and denial notification process (e.g., welcome and denial letters) with other Network Services Department staff
REQUIRED SKILLS:
- Typing skills at least 40+ wpm
- Ability to accurately enter data into information system as instructed
- Ability to prioritize workload and function w