Job Description

Enter Provider information into the database for purposes of proper claims adjudication, utilization management, reporting and provider directories.

Essential Functions & Responsibilities

• Reviews and analyses executed provider contracts for accuracy, completeness, and administrability.
• Enters acceptable provider contracts into the Provider File Maintenance module.
• Reviews pended claims due to issues with providers and assists in the resolution of the provider edit.
• Creates fee schedules for Provider contracts.
• Creates and maintains Provider Web Portal Accounts for contracted providers.
• Knowledge of CMS, Medicaid and state regulations as it relates to provider administration.Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
• Ability to come to work and work the regular schedule and shift for the position.
• Complies with and/or adheres to company HIPAA policies and procedures.
• Ensures integrity of data entered into company systems and/or databases.
• Compliance with all personnel policies and procedures.

Required Education and Experience

• High school diploma or general education degree (GED); And/OR
• one to two years related experience in a medical claims processing operation environment within the area of Provider Administration.(HMO’s or other Healthcare institution)