The Lead Provider Data Coordinator , under general supervision from the Supervisor, Network Data Validation, will validate change/add/term requests, audit provider data for accuracy, identify possible training issues and troubleshoot escalated system set up issues. The Lead Provider Data Coordinator will assist the Supervisor with providing leadership to the Provider Data Clerk, Data Coordinators I and II and coordinating the day to day workflow in the department. Provider data will be entered into multiple systems including but not limited to , HealthSuite, Excel spreadsheets and the Provider Repository (PR).
Principal responsibilities include:
· Update provider databases
· Verify provider demographic data quality and validate primary source as needed.
· Update “Provider not Found” physician demographic and contracting information into Diamond, HealthSuite & Provider Repository.
· Enter provider terminations, changes, additions, and contracts into various claims processing systems.
· Resolve various Claims issues including adding new vendor records and updating of existing contract records.
· Provide support to the Authorizations department to update providers with approved authorizations into various systems.
· Data owner of the Provider Directory database.
· Load all newly credentialed and re-credentialed providers to various databases.
· Make phone calls to providers directly and note any demographic changes into Excel spreadsheets by transcribing verified changes from call sheets.
· Scan necessary provider documentation and file in contract folders.
· Participate in the pulling of necessary documents and contracts for audits.
· Ensure accurate and timely completion of reports, projects and rosters from each Data Coordinator.
· Assist with ensuring all reporting for the following regulators are complete and in compliance:
o NCQA and HEDIS
· Keeps Supervisor abreast on any issues that affect the department.
· Work with Applications & Configuration Department to identify accurate contract set up .
· Monitor the “Provider Not Found” & “Fee Not Found Queue” daily to maintain in compliance and identify if the contracts were set up in error or it is an Apps issue.
· Distributes work assignments and projects to Data Coordinators as directed by Supervisor.
· Assist Supervisor with initiating internal department meetings for problem solving and resolution of issues.
· Coordinates with AAH internal departments on projects.
· Support LOA (Letter of Agreement) processes to make sure all documentation is received and entered correctly to ensure proper LOA configuration and set up.
· Work on escalated issues from Data Coordinator I, II & III that require extensive research and resolution.
· Research EDI claims with viewer or COD when needed to identify possible system error.
· Coordinate with Provider Services as needed to resolve incorrect provider billing, provider changes and other issues to directly contracted providers.
· Works with the Delegated PR Rep and/or analytics to validate provider changes when applicable.
· Validate “Pay to” address issues regarding returned checks or escalated provider issues in a timely manner.
· Collaborate with entire Data team to identify staff training and development needs for improved performance.
· Support continuous improvement of Data team effectiveness.
· Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
· Telephone: Make, receive, and document telephone calls from providers to verify demographic information.
· Transcription: Transcribe verified changes accurately and ensure data integrity.
· Computer: Enter/validate changes into databases, claims processing systems and spreadsheets.
· Auditing: Audit Provider Data Entry I , II & III previously assigned work to ensure its completion.
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Provide leadership of team and oversight of department workflows.
· Interface with multiple internal departments throughout AAH.
· Daily, weekly and monthly monitoring of data functions as it relates to regulatory. reporting, internal tracking and status reporting.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and/or mouse.
· Constant use of telephone headset.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders and objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
EDUCATION OR TRAINING EQUIVALENT TO:
· High School diploma required plus two years of data entry experience (or equivalents).
· One- two years of experience in managed care setting; Medicare/Medi-Cal experience preferred.
· Accuracy score of 97% or higher for at least 6 months (out of last 12 months) as a Provider Data Coordinator II or III.
· Demonstrated knowledge expert of Data Entry team policies and procedures.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Customer service oriented and resourceful.
· Ability to plan and execute projects independently.
· Ability to type 50 wpm.
· Ability to work in a multidisciplinary company.
· Ability to work overtime as needed.
· Proficient in use of computer software programs including entire Microsoft Office Suite of software (Word, Excel, PowerPoint, Access) and Microsoft Outlook.
· Ability to work in cooperation with others.
· Ability to communicate effectively, both verbally and in writing.
· Customer service background.
· Ability to work with others while completing multiple tasks simultaneously and successfully.
· Knowledge of HealthSuite preferred.
$24.56 - $36.84/hour