Provider Data Coordinator

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

This position is responsible for performing all activities related to provider data base management for the Provider Relations Department. The individual is a key department asset in performing provider database management, which includes the maintenance integrity, security and processing of data and files in an information system and data processing environment. Further, the position is responsible for ensuring the accuracy and timeliness of data entry of provider network data into the Provider Relations department software. Assist with all provider data management including contracted and non-contracted provider data and other software programs by GCHP. This position is also responsible for following all department and company policies; proactively and reactively seeking appropriate solutions to existing issues; fully accountable for maintaining positive working relationships with internal and external stakeholders and clients.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

* Lead face-to-face educational visits with physicians and their office staff to educate them on other Gold Coast Health Plan policy and procedures.

* Ability to answer many claims submission questions and have a good understanding of physician claims processing.

* Receives, researches, processes provider/location requests related to additions, changes, terminations, and ensures all requests are logged in appropriate database for performance measurement.

* Evaluates researches and resolves complex provider data maintenance requests and issues.

* Understands the credentialing process and provider impacts of the credentialing process

* Act as a liaison between Gold Coast Health Plan and the provider community to effectively resolve provider issues, address concerns and resolve problems.

* Reach out telephonically to physicians and their staffs to follow up on information needed by Gold Coast Health Plan.

* Be familiar with Gold Coast Health Plan's contract requirements for PCPs and Specialists.

* Coordinate and conduct regularly scheduled meetings with providers and follow-up on outstanding issues.

* Work with providers to adhere to contract and regulatory requirements.

* Identifies opportunities to improve processes to ensure efficient turnaround of issues and meets and exceeds established deadlines and performance standards.

* Identifies trends related to data structure/set up and reports trends with proposed solutions to management.

* Respond to provider requests, inquiries, and needs in a timely manner.

* Initiate face-to-face visits with the provider and office staff at the provider's location in order to respond to the individual provider needs.

* Research and resolve claims and authorization issues and/or elevate to other Plan management.

* Ensures provider directories are current and accurate.

* Develop and deliver presentations on various business topics to the provider community.

* Facilitates or assists with special projects and other initiatives to ensure provider data is complete and accurate.

* Other duties as assigned by management.

POSITION QUALIFICATIONS

Competency Statement(s)

* Management Skills - Ability to organize and direct oneself and effectively supervise others.

* Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.

* Customer Oriented - Ability to take care of the customers' needs while following company procedures.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

* Interpersonal - Ability to get along well with a variety of personalities and individuals.

* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

SKILLS & ABILITIES

Education: Bachelor's Degree (four year college or technical school), Field of Study: Business Administration, Health Care Administration or other related field preferredand/or

Experience:

• 4 plus years of experience in the health care field interacting directly with providers.
• Direct experience with physician offices and be familiar with physician claims related issues.

Computer Skills: Advanced computer skills included in the MS Office products.

Certifications & Licenses: A valid California Driver's License and insurance.

Other Requirements:

• Act as a liaison between the provider and Gold Coast Health Plan. Must be able to work the internal and external systems in order to achieve the desired result.
• Be familiar with claims related issues and be able to help resolve them.
• Be familiar with and able to interpret policy and procedures and various contracts.
• Respond appropriately to provider inquires in order to alleviate confusion or frustration.
• Become familiar with IKA internal business systems.
• Participate in audits and readiness assessments to assess contract compliance.
• Prioritize tasks in order to meet challenging deadlines.