What are the responsibilities and job description for the Provider Data Maintenance Specialist position at Driscoll Health?
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GENERAL PURPOSE OF JOB:
The Provider Data Maintenance Specialist is responsible for researching and gathering provider data and converting it into meaningful information/reports/file used by the Driscoll Health Plan in the Tapestry claim system.
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 as required.
- Maintains utmost level of confidentiality at all times.
- Adheres to hospital 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.
- Change Files ensuring data integrity of all provider data being loaded into DHP, claims and authorizations systems.
- Provides resolution of all DHP Claims Provider Not Found Queues to required Provider data for adjudication on a Participating or Non-participation basis expeditiously as required to meet state-mandated claims turnaround time frames.
- Proficient in use of the State of Texas Master Provider File (MPF) and NPPES NPI Registry in regard to Provider Data required to load Provider information.
- Utilizes DHP CRM to communicate with DHP Departments to provide required provider data to the appropriate department for system load.
- Performs other related work as required.
EDUCATION AND/OR EXPERIENCE:
- Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying. Degree Preferred.
- Typically has 6 years’ experience in Texas Medicaid MCO Provider data Management.
- Knows fundamental concepts, practices and procedures of particular field of specialization.
- Preferred healthcare industry experience or related experience, prior experience working with Medicaid Managed Care claims system a plus.
- Experience with relational database querying tools and critical thinking skills to determine the appropriate course of action to meet Provider Data Load Requirements.
