Provider Data Representative

Position Summary
The role ensures provider data integrity to support accurate claims payment, credentialing compliance, provider directory accuracy, and network participation. The Representative partners with Provider Relations, Credentialing, Provider Data, Claims Operations, and contracting to keep provider information complete, accurate, timely, and compliant with organizational standards.
Key Outcomes & Success MetricsDirectory accuracy & completeness: Meet internal standards and regulatory expectations; reduce member/provider complaints due to directory errors.
Maintenance timeliness: Process updates, additions, terminations, and changes within SLAs; reduce cycle time and backlog.
Data integrity: Improve audit scores; lower claims‐ impacting data error rates; maintain accurate NPIs, TINs, specialties, practice locations, affiliations, licenses, and EFT details.
Roster reconciliation effectiveness: Validate rosters against credentialing, enrollment, terms & conditions, claims, and directory data; correct discrepancies promptly.
Credentialing & enrollment support: Ensure data readiness for onboarding and re-credentialing; reduce participation activation delays.
Operational reporting: Provide clear dashboards and logs for productivity, turnaround times, accuracy, and issue remediation.
Essential Duties & Responsibilities
Data Intake & Maintenance OperationsProcess provider roster submissions and updates.
Maintain accurate provider demographic, enrollment, and participation records.
Validate and update NPIs, TINs, specialties, practice locations, EFT details, and affiliations.
Ensure timely changes supporting accurate claims payment and directory publication.
Roster ReconciliationReconcile provider rosters against credentialing, claims, enrollment, and directory systems.
Identify discrepancies impacting participation, claims payment, or directory accuracy.
Coordinate corrections with Provider Relations, Credentialing, and Provider Data teams.
Credentialing & Enrollment SupportValidate provider demographic information for credentialing/re-credentialing.
Identify and resolve enrollment and participation discrepancies.
Ensure data requirements are complete for onboarding and participation activation.
Data Quality & GovernanceAudit provider records for completeness, accuracy, and compliance.
Monitor directory accuracy, quality scores, and claims‐ impacting error rates.
Support development of data standards, QA programs, and process improvements.
Claims & Operational SupportIdentify provider data issues affecting claims adjudication, reimbursement, and participation.
Collaborate with Claims Operations to resolve data discrepancies; support root‐ cause analysis and remediation.
Reporting & AnalyticsProduce provider data quality reports, discrepancy logs, and audit results.
Track maintenance productivity, turnaround times, and accuracy metrics.
Provide insights to leadership to guide operational improvements.
Provider & Stakeholder CommunicationCommunicate data requirements and discrepancies to credentialing, enrollment, and provider relations teams.
Provide clear documentation for provider updates and requests.
Process Improvement & ToolingRecommend system enhancements, automation opportunities, and updated workflows.
Support implementation of new processes, templates, and operational tools.
Qualifications
RequiredBachelor's degree preferred.
2–5 years of experience in provider data, credentialing, enrollment, or health plan operations.
Strong analytical skills and proficiency in Microsoft Excel.
Exceptional attention to detail and accuracy.
PreferredExperience supporting federal or government‐ sponsored healthcare programs.
Knowledge of provider directory regulatory requirements and healthcare data standards.
Experience with provider portals, enrollment systems, or enterprise provider data platforms.
Skills & CompetenciesData governance and quality management.
Analytical thinking and problem solving.
Process improvement mindset.
Attention to detail.
Strong written and verbal communication.
Collaboration and teamwork.

Work arrangement
Yes