Provider Data Resolution Spec

2 weeks ago

Phoenix, United States TriWest Healthcare Alliance Full time

**Profile**:

- We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TX, UT, VA/DC, *WA, WI & WY only)Veterans, Reservists, Guardsmen and military family members are encouraged to apply**Job Summary**

**Education & Experience**

**Required**:

- High School Diploma or GED
- 2 years of varied responsible experience with computer database programs
- 2 years of Health Care experience such as claims, provider data or authorization or referral processing
- Experience with Microsoft Suite (including, but not limited to, Word, Excel and Outlook)

**Preferred**:

- 1+ years of Health care claims resolution experience
- Experience using a Provider Data Management System, Claims System, or Authorization/Referral system

**Key Responsibilities**
- Resolves Provider data discrepancies related to claims processing, including contract reimbursement rates within the allotted timeframe.
- Manages daily follow up of Provider data correction requests and issues to ensure databases are current and accurate.
- Ensures and maintains accurate data within the Provider Claims and Authorization databases.
- Contacts providers to verify all credentialing, claims, and billing information.
- Ensures appropriate tax documentation is obtained and imaged for Provider files.
- Corrects reimbursement issues within claims payment system.
- Develops, maintains, and processes reimbursement terms ensuring correct claims payment and downstream processing.
- Reviews Provider contract language and identifies when a contract is out of compliance. Processes Provider contracts, run reports, and responds to inquiries regarding contract compliance issues; images and indexes contracts and return images to network subcontractors; conducts quality assurance activities to ensure image quality and completion of image activities. Queries primary sources and OIG, as applicable, to verify Provider credentials and qualifications.
- Professionally and concisely communicates in writing and by phone, information and/or instructions for updating and correcting databases.
- Resolves 1099 and W9 discrepancies.
- Assist in the development and update of protocols and procedures.
- Coordinates with Claims and other departments on Provider database related issues.
- Resolves daily error reports which include data rejected from claims system including data rejecting from all downstream systems.
- Performs other duties as assigned.
- Regular and reliable attendance is required.

**Competencies**

**Commitment to Task**:Ability to conform to established policies and procedures; exhibit high motivation.

**Communication / People Skills**:Ability to influence or persuade others under positive or negative circumstances; adapts to unique styles; listens critically; collaborates.

**Coping / Flexibility**:Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach.

**High Intensity Environment**:Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

**Organizational Skills**:Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

**Problem Solving / Analysis**:Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

**Technical Skills**:Proficient with key databases, including Claims System, Medical Management System, Authorization/Referral Systems, and Provider Information Management System(s); working knowledge of claims reimbursement methodology and medical coding; healthcare or managed care experience

**Working Conditions**

**Working Conditions**:

- Availability to cover any work shift
- Works within a standard office environment, with mínimal travel
- Extensive computer work with prolonged periods of sitting
- Must be a U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DOD) background adjudication

**Company Overview**:
**Taking Care of Our Nation’s Heroes.**

**It’s Who We Are. It’s What We Do.**

Do you have a passion for serving those who served?

**Join the TriWest Healthcare Alliance Team We’re On a Mission to Serve®**

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

**DoD Statement**:
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

**How To Apply**:
In order to apply, you must submit your current resume through PeopleSoft in an electronic format, and submit a completed Internal Interview Request form to Human Capital. The form can be found on TriNet un

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