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Provider Data Specialist

Company: Community Health Plan of Washington
Location: Seattle
Posted on: May 28, 2023

Job Description:

This position is available fully remote in Washington State.

Job Summary

This position is responsible for interpreting, analyzing, researching and maintaining accuracy of provider file data across multiple data bases, including the accuracy of the provider directory.

Essential Functions

Act as the technical provider data expert, following state and federal guidelines, and Community Health Plan of Washington provider contracts.
Prepare, categorize, and analyze source documents, identify and interpret data to be updated in claims and credentialing systems, and online provider directory. Accurately add and update Provider Data in credentialing database. Prepare Provide Add Change Term (PACT) forms to submit for provider and vendor record changes in the claims payment system.
Resolve issues with PACT forms that require analysis or clarification.
Serves as a technical provider data contact for providers, acting as a liaison regarding provider data updates, problematic issues, claims questions.
Effectively communicate responses to provider groups. Performs outreach via telephone and written communication with contracted Providers for quality assurance reviews, data collection of provider demographics (address, phone, email, website, fax numbers and verification of contracts). Reviews their full roster to validate the accuracy of Provider Data and verify practicing location for each individual provider. Resolve questions and inconsistencies with Provider Data.
Complete and submit reports to CMS/HCA to provide narrative summary of quality assurance review, including next steps as a result of the analysis.
Present quality assurance results to provider groups, leadership, PDS, other Community Health Plan of Washington business areas.
Research, resolve and respond to claims processing and provider reimbursement issues related to contract payment and accurate configuration of Provider Data in the claims system.
Identify and initiate claims processing adjustments as needed interfacing with internal departments.
Inventory Control including distribution and monitoring of incoming requests from Providers and internal Departments.
Gathers business system requirements and performs User Acceptance Testing.
Analytic and research support for Encounter Data.
Provide feedback to the configuration team to ensure provider contracts are configured in the system correctly.
Performs audits of varied scope on Provider Data. Assist in team audit process and State and CMS audits (CMS financial, provider network adequacy, TEAMonitor, NCQA, HEDIS, etc.)
Initiate team projects that enhance quality assurance, streamline workflow, and identify process improvements by using Lean Six Sigma methodologies. Regularly report results to management and project owners.
Develop and provide technical training and coaching to new members of team. Create and maintain training materials, procedures, resource documents and reports.

Other Functions:

Other duties as assigned.
High School diploma or equivalent required.
Associate's Degree in Health Care or a related field; or an equivalent combination of education and highly relevant experience preferred.
Prior Related Experience
1-3 years' work experience with Customer Service, Claims and/or Provider Data analysis required. Provider Relations preferred.
Previous experience in a healthcare/insurance setting required. Experience with Managed Care or Commercial health insurance, Provider Data Services, Provider Network Administration preferred.

Employment Eligibility

Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

Knowledge, Skills, and Abilities

Demonstrated ability to gather data, analyze, summarize results, and create reports.
Demonstrates problem solving and research skills with the tenacity to follow through on research and ensure timely and accurate results, meet deadlines.
Ability to comprehend and work efficiently with systems of high complexity. Explain complex information in easy-to-understand terms, exhibiting patience and understanding when working with or training others.
Ability to perform a variety of complex tasks.
A demonstrated friendly, competent and professional attitude and demeanor and the ability to present a positive and professional image to all internal and external customers.
Ability to present to both small and large groups.
Maintains knowledge of state and federal regulatory requirements as it relates to the accuracy and data content of provider data, including provider directory.
Commitment to a philosophy that supports single contact resolution.
Ability to work with minimal supervision.
Able to work under pressure and time constraints.
Solid organizational skills and accurate work results, and strong attention to detail.
Strong oral and written communication skills, including public speaking.
Excellent time management skills.
Proficient in Microsoft Office Suite.


The position is FLSA Non-Exempt (hourly) and is eligible for overtime. The position is also eligible for as an annual incentive based on company, department, and individual performance goals. Full and Part - time employees have the option to enroll in medical, dental, vision and voluntary life insurance benefits, and 401(k) retirement benefits effective the 1st of the month following or coinciding with their start date. CHPW provides a 6% 401(k) employer match, Basic Life, Accidental Death and Dismemberment insurance, short and long-term disability, financial coaching, and wellness programs at no cost.

CHPW employees start earning 17 days of Paid Time Off (PTO) and receive 40 hours of community service for volunteer time, and two floating holidays immediately. The company offers 10 standard holidays, paid jury duty and compassion time.

CHPW offers a monthly stipend to offset work-from-home expenses for roles that are 100% remote.


Sensory :

Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical :

Extended periods of sitting, computer use, talking and possibly standing.
Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
Frequent torso/back static position; occasional stooping, bending and twisting.
Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching.


Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.


Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.


Community Health Plan of Washington employees will encounter protected health information in the regular course of their work at and for Community Health Plan of Washington. Community Health Plan of Washington is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role. All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164. In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community Health Plan of Washington policies can be cause for termination.

PHI is defined at 164.103 as:

"Protected health information means the individually identifiable health information that is (i) Transmitted by electronic media; (ii) Maintained in electronic media; (iii) Transmitted or maintained in any other form or medium.

Individual means the person who is the subject of protected health information.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan of Washington:

Frequent - The position has frequent and/or daily access and responsibility for PHI. Need to know.

In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.

This job description is intended to describe the general content and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties . click apply for full job details

Keywords: Community Health Plan of Washington, Seattle , Provider Data Specialist, Other , Seattle, Washington

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