PR Data Maintenance Spec

Where compassion meets innovation and technology and our employees are family.

Thank you for your interest in joining our team! Please review the job information below.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration as required.

• Maintains the utmost level of confidentiality at all times.
• Adheres to DHS/DHP policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 
• Ensures the integrity of provider data, including research, data extraction, processing, storage, manipulation, analysis, and distribution of Provider Data from Credentialing, Contracting, and State and Federal databases.
• Provides resolution of all required provider data updates in the claims administration system for participating or non-participating.
• Is a Subject Matter Expert on the State of Texas Master Provider File (MPF) and the NPPES NPI Registry regarding Provider Data required to load Provider information
• Communicate with DHP Departments as appropriate to resolve issues regarding provider data.
• Is a Subject Matter expert on DHP Credentialing and Contracting system’s Provider Data.
• Maintains the highest attention to detail to ensure accurate provider data additions
• Screens, loads, and updates provider EFT requests and updates
• Respond to provider requests for status updates and follow-ups
• Sends required documents to providers as needed
• Evaluates provider submissions of initial credentialing documents for both completeness and accurate information
• Requests additional information (if required) and sends the requested documents to providers
• Loads requests to SharePoint
• Loads requests from SharePoint to ECHO
• Validates Texas Medical Board Delegations (for mid-level providers)
• Evaluates credentialing requests from Out of Service Area Providers and prepares findings for weekly committee review
• Evaluates requests from previously terminated/withdrawn providers and prepares findings for weekly committee review
• Follows approved DHP provider termination workflow to terminate providers, including both ECHO and Tapestry updates (submission of termination CRM)
• Validate if the term is only for the provider, or if the contract (in ECHO) and the vendor (in Tapestry) need to be terminated as well
• Submits terminations processed by the Credentialing Specialists to Tapestry
• Completes record changes, including but not limited to: address changes, demographic changes, contact information changes; ensuring that proper documentation is loaded to the provider's ECHO record and (if needed) Tapestry record
• Performs other duties as assigned to facilitate departmental and organizational needs.

Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying. Degree Preferred.

Experience

Typically has 6+ years’ experience in Texas Medicaid MCO Provider Data Management

Knowledge

Knows fundamental concepts, practices and procedures of particular field of specialization.

Responsibilities

Established own procedures with little supervision.