Provider Data Services Consultant
Job Description :
Researches, manipulates and prepares complex data to document program activities and reports on its results. Provides oversight to data quality and provides feedback to various areas in order to improve service delivery and enhancement to design efforts. Develops a consultative relationship with internal functional areas.
Fundamental Components/Job Description:
* Performs ongoing research, and support tasks for existing systems.
* Works to resolve provider disputes, pended claims and encounter health plan work.
* Works directly with BIS, IT, CRSA, HPRA, CSS and PDS to ensure delivery of service requests and configuration changes to support health plan operations.
* Ability to identify trends and defects, perform research and remediate core issues through submission of tickets. This includes having expertise with PCRs and SCRs.
* Influences enhancements to business processes and system infrastructure to improve data quality availability and access.
* Analyzes complex data for trends and provides in-depth root cause analysis.
* Consults with claims manager on a regular basis to ensure progress is ongoing to drive to completion of projects.
* Translates complex data into constructive data and information and makes recommendations.
* Defines, identifies, develops and implements information products to support strategic business and operational planning.
* Illustrates complex information in a clear concise manner.
* Provides workgroup support on projects.
* Influences changes/enhancements to business processes, policies, and system infrastructure to improve information quality, availability and access.
* Excellent verbal and written communication skills.
* Understanding of provider configuration in core platforms
* Claims and/or billing experience preferred
* BS/BA or equivalent experience and 5+ years of experience in Medicaid managed care, preference with MediCal.
- Minimal experience in understanding contract configuration in QNXT.
- Familiarity with covered benefits.
- Work with Claims Department and Appeals Department.
- Understand the difference between disputes, appeals and grievances.
BS/BA or equivalent experience and 5+ years of experience in Medicaid managed care, preference with MediCal.
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.