Claims Processor/Data Entry

The CLAIMS PROCESSOR/DATA ENTRY RESOURCE will ensure the integrity of the provider directories for all corporate products are accurate and timely by performing maintenance of the provider file database. The candidate will do this by coordinating, updating, and maintaining the contracting administration and enrollment processes for all participating professional and institutional provider files to ensure eligibility, demographic, reimbursement and risk sharing requirements are met. In addition, s/he contributes to the development and maintenance of relations with the provider community on an operational basis.

JOB QUALIFICATIONS AND TECHNICAL COMPETENCIES

- Two years' experience in claims processing, customer service, provider setting or general office work involving data entry or accounting
- Proficiency PC skills and prior experience in a PC environment; knowledge of and experience working with Microsoft Word, Excel, and Lotus Notes preferred
- Demonstrated research skills in identifying problems, developing and implementing both short and long-term solutions
- Demonstrated ability to organize and prioritize work and adapt to shifting workloads
- Detail oriented with proven accuracy skills
- Ability to apply mathematical concepts and calculations
- Ability to communicate effectively both orally and in writing
- Knowledge of medical terminology and claims coding preferred
- Demonstrated ability to work well with others and work in a team environment
- Ability to adapt to a fast-paced environment and learn and retain new or evolving information and procedures
- Ability to apply proper punctuation, spelling, grammar, and proofreading skills
- High school degree or GED

ESSENTIAL FUNCTIONS

- Research all provider applications and/or contracts for all products to ensure eligibility requirements are met prior to panel acceptance. This includes verification of licensure status with the appropriate medical boards, departments or agencies. This also includes determining how provider activities affect contractual arrangements, reimbursement methods, and membership assignment to care providers, call sharing arrangements, demographic information and coordinating these activities with the appropriate internal department, provider office or other. Upon verification, perform all provider file entry and/or maintenance for all professional, institutional and allied providers.
- Maintain the provider file for all non-contracted professional, institutional and allied providers. Frequent contact with provider offices and facilities is necessary to gather all pertinent billing information for claims adjudication and payment. All system updates must be properly documented and logged for tracking purposes.
- Issue provider identification numbers (PIN) to new providers. Ensure that all provider files are properly cross-referenced for EMC, Medicare Crossover, ITS, and The Regence Group transactions and reporting.
- Resolve provider file discrepancies as the result of claim edits, contracting changes, changes in primary care status, directory changes, change of address notifications and changes received from other internal departments. This may include coordination with inter and intra departmental employees at all levels to investigate and resolve issues.
- Responsible for contacting providers via phone or correspondence as needed.
- May interpret and apply contract terms for each product as it pertains to provider eligibility and termination requirements in order to comply with provider file activities and provider notifications.
- Respond to internal and external inquiries regarding provider file, and/or contracting status, in a timely and courteous manner.
- Responsible for creating and implementing action plans and coordinating projects and tasks.
- Research and recommend criteria and policies relating to provider administration.
- Edit and proof of all provider directories published for all lines of business.
- Maintain a customer focused philosophy toward being responsive to answering provider file problems or questions in a timely fashion.
- Maintain department files for provider contracts and correspondence.