Job Description

TEMPORARY POSITION

FLSA Status: Non-Exempt
Department: Provider Network Management
Reports To: Manager, Provider Data, Credentialing and Reporting

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

The Provider Database Coordinator is responsible for the timely and accurate entry and maintenance of provider data into Santa Clara Family Health Plan’s (SCFHP) core operating/claims system to support health plan operations for all lines of business. The Provider Database Coordinator has primary responsibility for researching, documenting, resolving and escalating provider claims and billing issues to the Manager, Provider Database and Reporting, in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and SCFHP business requirements, to achieve Department performance objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Maintain a working knowledge of SCFHP’s provider network structure and contracting relationships and apply to day-to-day management of the information contained in the core operating/claims system.
2. Update and maintain SCFHP’s core operating/claims system with provider demographic and contract information to support primary care provider assignment, utilization management and claims processing.
3. Act as primary liaison between the Provider Network Management and the Claims departments related to data entry required to facilitate timely and accurate payment of claims and questions regarding demographic, contract or pay-to information for contracted and non-contracted providers.
4. Work collaboratively with the Information Technology (IT) configuration manager or their designee to communicate requests for contract configuration for new and changing provider agreements.
5. On a monthly basis, create and maintain reports in Excel and/or Word to track outstanding work, monitor provider additions, terminations and changes and generate reports as needed for business and regulatory purposes.
6. Work with Provider Database Analyst(s) and/or Manager to validate correct provider and contract configuration in core operating/claims system to ensure accuracy of work.
7. Create and maintain current procedures and work instructions for all work processes.
8. Cross-train on and provide back-up support, when necessary, to enter information into other provider data management systems that are the systems of record for provider demographic, credentialing and contract data to support information entered in core operating/claims system.
9. Take initiative to gain an understanding of applicable regulatory and industry guidelines related to billing in order to troubleshoot data entry and provide feedback for SCFHP policies and procedures.
10. Assist IT with system testing activities related to provider data during times of implementation of new systems, configuration changes and/or upgrades to existing systems.
11. Perform other related duties as required or assigned.

REQUIREMENTS – Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. High School Diploma or GED. (R)
2. Minimum two year of experience with managed care or healthcare settings. (R)
3. Experience in health care billing or claims payment experience. (D)
4. Attention to detail and a strong focus on the quality of work related to data entry and validation. (R)
5. Knowledge of relational databases such as SQL and Microsoft Access from a user standpoint. (D)
6. Knowledge of CPT, HCPC, Rev and ICD codes used for medical claims billing. (D)
7. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support department operations as dictated by business needs. (R)
8. Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word and Excel. (R)
9. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
10. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
11. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
12. Ability to maintain confidentiality. (R)
13. Ability to comply with all SCFHP policies and procedures. (R)
14. Ability to perform the job safely with respect to others, to property and to individual safety. (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.