Provider File Representative

Highmark Inc. Pittsburgh , PA 15201

Posted 2 months ago

Company :

Gateway Health Plan

Job Description :

JOB SUMMARY

This job is responsible for corporate provider enrollment and provider file maintenance across all markets including, enrollment, contracting and demographic provider information. The incumbent ensures compliance with BCBS and CMS requirements, DOH regulations, internal, private business and governmental audits. Reviews and processes additions, updates, and deletions of provider information in the Provider File database. Ensures executions of data entry and updates are completed in a timely and accurate manner.

ESSENTIAL RESPONSIBILITIES

  • Maintain accurate data in provider file data systems. Common transactions include: maintaining and initial setup of assignment accounts (AA) from the AA applications, updating group and provider affiliations from AFBs and written requests, 1099 tax ID updates, UPIN/PTAN and/or Medicare Welcome Letter information, state license update, enumerating providers, name changes, demographic data updates, specialty changes, hospital affiliations, network affiliations, network terminations, and facility agreement data, Institutional non-contracted files.

  • File Maintenance Analysis.

  • Apply complex and detailed guidelines in the review process of the submitted requests.

  • Ensure the documentation application complies with BCBS, DOH, CMS, MSBCBS and Highmark requirements.

  • Routinely contact external sources such as the Provider offices, state licensing agencies and provider reps to collect or clarify information or documentation, which in turn must be reviewed and evaluated against the established guidelines.

  • Ensure the file meets all regulations prior to updating the provider file.

  • Contact external sources to collect or clarify information or documentation which in turn must be reviewed and evaluated against the established guidelines and procedures to ensure the file meets all policy and procedures in conjunction with regulations.

  • Maintain and update internally required data elements which include but are not limited to: assigned Blue Shield provider numbers, National Provider Identifier (NPI), CMS required provider identifiers for compliance with corporate and federal contracts.

  • Responsible to educate providers for obtaining and updating provider identifiers.

  • Other duties as assigned or requested.

EDUCATION

Required

  • High School Diploma or GED

Substitutions

  • None

Preferred

  • None

EXPERIENCE

Required

  • 2 - 5 years of related, progressive experience. Grandfathered experience requirements effective August 2016.

Preferred

  • None

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • None

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is travel required?

No

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

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Provider File Representative

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