Santaclara Family Health Plan San Jose , CA 95111
Posted 2 weeks ago
FLSA Status: Non-Exempt
Department: Provider Network Management
Reports To: Manager, Provider Database and Reporting
Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
GENERAL DESCRIPTION OF POSITION
The Provider Database Coordinator is responsible for the timely and accurate entry and maintenance of provider data into Santa Clara Family Health Plan's (SCFHP) core operating/claims system to support health plan operations for all lines of business. The Provider Database Coordinator has primary responsibility for researching, documenting, resolving and escalating provider claims and billing issues to the Manager, Provider Database and Reporting, in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and SCFHP business requirements, to achieve Department performance objectives.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.
Maintain a working knowledge of SCFHP's provider network structure and contracting relationships and apply to day-to-day management of the information contained in the core operating/claims system.
Update and maintain SCFHP's core operating/claims system with provider demographic and contract information to support primary care provider assignment, utilization management and claims processing.
Act as primary liaison between the Provider Network Management and the Claims departments related to data entry required to facilitate timely and accurate payment of claims and questions regarding demographic, contract or pay-to information for contracted and non-contracted providers.
Work collaboratively with the Information Technology (IT) configuration manager or their designee to communicate requests for contract configuration for new and changing provider agreements.
On a monthly basis, create and maintain reports in Excel and/or Word to track outstanding work, monitor provider additions, terminations and changes and generate reports as needed for business and regulatory purposes.
Work with Provider Database Analyst(s) and/or Manager to validate correct provider and contract configuration in core operating/claims system to ensure accuracy of work.
Create and maintain current procedures and work instructions for all work processes.
Cross-train on and provide back-up support, when necessary, to enter information into other provider data management systems that are the systems of record for provider demographic, credentialing and contract data to support information entered in core operating/claims system.
Take initiative to gain an understanding of applicable regulatory and industry guidelines related to billing in order to troubleshoot data entry and provide feedback for SCFHP policies and procedures.
Assist IT with system testing activities related to provider data during times of implementation of new systems, configuration changes and/or upgrades to existing systems.
Perform other related duties as required or assigned.
REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
Santaclara Family Health Plan