Provider Operations Specialist

Base Salary Range : $31,991.73 - $51,186.77 Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer.

All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion : PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Responsible for various activities related to the provider network database for both Commercial and Government lines of business which may include any or all of the following : database maintenance, reporting and extracting data for various reports and analyses, initiating database improvement.

Maintain all necessary data elements for Groups, Providers and Facilities in our Provider database for all states PacificSource services while compliantly meeting HEDIS and NCQA measurements.

Essential Responsibilities :

• Provides internal support to the Provider Network Department.
• Monitoring the faxes, emails, mail, files and other sources of incoming provider data notifications to ensure that provider network data is processed in a timely manner.
• Entering provider data into PacificSource systems for new and re-credentialed network providers accurately and in a timely manner, consistent with department service level expectations and individual specialists' performance objectives.

Ensuring accurate contract rows are added to ensure correct claims payments.

Verifying licensure, Medicare and Medicaid eligibility through compliance approved tools; State license websites, Nordian Health solutions, CMS Ordering and Referring Information website, Medicare.

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• Enter non-par facility / provider in the claims system for claims that pend. Verifying eligibility through approved sites, NPI through NPPES Registry, and adding non-par contract rows for correct payment processing.
• Attend meetings on a regular and ad hoc basis.
• Validates the data to be housed on provider databases and ensuring adherence to business and system requirements of customers as it pertains to contracting, network management, and credentialing, while maintaining current on up-to-date rules and regulations
• Supports the ongoing maintenance and data integrity of the provider information and provides research analysis as needed.
• Building the facility / provider file in the claims' payment system(s).
• Review and processing of claims within Facets. Attaching claims to the correct Practitioner, Facility, and / or Group record to ensure correct claims payment.

Includes reviewing the claim submission has been done appropriately based on state and government regulations in processing claims payments.

Determines the accurate assignment of the appropriate network agreements that define payment specifications for the individual provider group or facility.

Utilizing agreement matrix tools for states, lines of business, and contract agreements.

• Researches and responds to detailed provider inquiry issues routed from customer / provider service departments. Collaborating when needed with Service, Contracting, and / or Credentialing.
• Responsible for manning the Provider Network phone queues, providing exceptional customer service when assisting callers;

both internal and external. Having a strong und To view the full job description,