Under the direction of the manager, the Provider Data Specialist is responsible for maintaining accuracy of provider data in both internal and external databases. This position is expected to work effectively with internal and external contacts in an effort to meet all regulatory and industry provider data quality and accuracy standards. This position performs a variety of administrative and managed care contract support functions to ensure health plan requirements for provider enrollment and reimbursement are identified, communicated and coordinated both internally and with Phoenix Children's Medical Group contracted health plans.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
- Completes health plan enrollment applications for PCMG via paper or electronic means, as necessary assuring that plan deadlines are met. Serves as primary contact for any provider information needs and works with health plans to resolve provider data issues; Tracks initial and follow-up communications / correspondence with providers, health plans and others, as needed. Prepares materials for internal and external managed care communications and correspondence related to provider enrollment.
- Performs timely and accurate data entry. Identifies extraordinary information, discrepancies, time gaps, and other idiosyncrasies that could adversely impact ability to enroll providers and, ultimately to bill and to obtain reimbursement for services rendered.
- Maintains Internal and external databases to assimilate and track health plan enrollment including (but not limited to) the NPPES Website, PECOS and CAQH systems to submit provider data as required by some health care organizations to credential individual providers. Prepares standard and ad-hoc reports as needed. Analyzes and maintains all reports related to provider enrollment with contracted health plans. Conducts audits of health plan provider information to ensure accurate provider data is conveyed to plan.
- Collects all credentialing and other data needed to enroll Phoenix Children's Medical Group (PCMG) providers in health plans. Interacts with other internal departments and provider to secure needed information. Maintains provider paper and electronic data files for all PCMG providers, including pertinent demographic and credential information needed for provider enrollment. Scans, files, and archives documentation as needed.
- Participates in the evaluation and/or development of new procedures, protocols, and quality improvement initiatives. Proactively evaluates practices and assists in efforts to enhance effectiveness of methods.
- Performs miscellaneous job related duties as requested.