Provider Data Specialist Resume Sample
Anika Upton
3790 Howell Burgs,
Detroit,
MI
+1 (555) 271 7898
Work Experience
Provider Data Specialist
02/2017
-
PRESENT
Dallas, TX
- Experience using computer applications, including the Microsoft Office Suite, as well as the ability to learn applications relevant to the position
- Responsible for obtaining and maintaining current knowledge of network compliance requirements to ensure Health Alliance meets or exceeds all requirements for current and expansion markets
- Lead or participate in department and corporate projects providing expertise on provider networks and regulatory contract provisions
- Develop and manage department and cross functional systems and workflows related to network composition
- Manage necessary vendor agreements
- Conduct ongoing monitoring of network composition against standards to ensure compliance and support business goals
- Create standard and ad hoc network reporting to support business needs of the organization. Examples include but are not limited to - access standard analysis, network analysis, client disruption reports
- Responsible for managing timelines with internal teams to ensure provider’s needs are met
Senior Provider Data Specialist
06/2012
-
11/2016
Phoenix, AZ
- Accurately enter and update provider data into Beacon’s proprietary FlexCare and Raintree systems for both In Network and Out of Network providers
- Enter and maintaining participating and non-participating provider data
- Responsible for research and analysis of projects maintaining provider data
- Capable of understanding standard contract language
- Review health care claims
- This role requires dependability, analytical thinking, willingness to learn and attention to detail
- Accurately enter provider facility, group and individual practitioner information into Beacon’s system
Education
Herzing University - Atlanta
2006 - 2011
Bachelor's Degree in Healthcare
Professional Skills
- Strong keyboard / computer skills
- Apply research and problem solving skills in resolving business needs
- Competent written and oral communications skills
- Professional office work experience or Experience in the Healthcare Industry
- Coaching / training experience
- Demonstrated understanding of internal processes and procedures for loading, maintaining, and / or resolving system feed related errors
- Experience utilizing at least one of the following Provider or Claims databases: NDB and / or CSP Facets
How to write Provider Data Specialist Resume
Provider Data Specialist role is responsible for research, database, training, auditing, reporting, design, insurance, government, software, languages.
To write great resume for provider data specialist job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Provider Data Specialist Resume
The section contact information is important in your provider data specialist resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Provider Data Specialist Resume
The section work experience is an essential part of your provider data specialist resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous provider data specialist responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular provider data specialist position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Provider Data Specialist resume experience can include:
- 6+ months of experience with workforce effectiveness practices
- Use software, hardware, and peripherals related to job responsibilities, including MS Office Ability to multi task and prioritize
- Provider data auditing experience
- 6+ months of experience in medical claims processing
- Experience with NDB (loading demographic and contractual)
- Direct experience working with provider databases and/or provider demographic data in claims payment systems
Education on a Provider Data Specialist Resume
Make sure to make education a priority on your provider data specialist resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your provider data specialist experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Provider Data Specialist Resume
When listing skills on your provider data specialist resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical provider data specialist skills:
- Experience of data entry experience
- End to end loading and error resolution, including validating data feeds between NDB and CSP Facets claims platform
- Experience processing enrollment data entry or working within a Managed Care Organization with direct interaction with the Enrollment Department
- Build effective working relationships and coordinate activities with staff across various departments
- Experience working with medical claims
- Experience with Microsoft Excel (pivot tables, sorting, and VLOOKUP)
List of Typical Experience For a Provider Data Specialist Resume
1
Experience For Senior Provider Data Specialist Resume
- Intermediate requires solid analysis and research skills to resolve various provider related issues
- Advanced requires strong project tracking
- Experience in the healthcare industry and/or data entry
- Demonstrated ability to complete multiple projects in both a timely and quality manner
- Accountable for researching and resolving claims pended for provider data issues to meet expedited performance metric
- Knowledgeable of current NCQA, CMS, DHCS, DMHC and other regulatory body’s credentialing standards
- Accurately enter information into Beacon’s system of record
- Serve as liaison to customers and customers’ provider networks to ensure timely provider data updates are received, processed, and extracted in accordance with client requirements to ensure timely and accurate claim repricing
2
Experience For Provider Data Specialist Resume
- Accountable for the implementation and maintenance of MPI contract provisions in eProvider for MPI direct contracted networks (commercial and Government networks)
- Communicate business requirements to technical staff, confirming specifications are met through testing and quality assurance activities and recommend changes and alterations to ensure provider data load requirements are met
- Provide direction to data staff to ensure electronic output data is researched and loaded in provider database
- Project manages provider data initiatives
- Service coordination responsibilities (collectively less than or equal to 20% of time)
- Review, analyze and report on Service Tracker data for trends, gaps and variances. Provide consistent feedback and suggestions for improvements
3
Experience For Senior Provider Data Specialist Resume
- Escalate unresolved issues appropriately and provide complete responses to the client
- Serve as liaison to customers and customers' provider networks to ensure timely provider data updates are received, processed, and extracted in accordance with client requirements to ensure timely and accurate claim repricing
- Extensive work experience within own function. Work is frequently completed without established procedures
- Meets and / or exceeds established performance goals to ensure quality
- Researches potential claim data issues identified in the daily Provider Verification Report (PVR) or claims inbound queue
- Resolves pended claims within specified turnaround time and communicates directly with claim colleagues on any delays
4
Experience For Provider Data Specialist Resume
- Solve moderately complex problems and/or conduct moderately complex issues in workgroup and consulting with provider relations and contracting teams for resolution as appropriate and escalating to supervisor as needed
- Responsible for receiving provider information, translating and maintaining all provider transactions in accordance with Tufts Health Public Plan policy and procedures
- Ensures timely receipt and accurate processing of Provider Information Form (PIF) initiated by contracting or provider
- Receive, log and ensure timely response to provider inquires; phone calls, emails, websites questions/concerns etc
- Collaborates between external provider representatives, internal stakeholders and providers to respond to inquiries related to provider data
- Resolve provider claim issues associated with provider set up and triage other escalated provider claims issues between Customer Service claims queue and the Claims department
- Researches data discrepancies and requests from other departments within required time frames including but not limited to, e.g., claims, customer service, medical management, behavioral health, contracting and credentialing
- Runs, researches and updates data quality reports to support departmental quality control processes
5
Experience For Senior Provider Data Specialist Resume
- Adheres to established department standards for data quality and productivity
- Intermediate access with Access and Excel
- Knowledge of NCQA standards for Provider Data Integrity
- Knowledge of CMS, DOI, and State regulations
- Data entry and maintenance
- Develop and maintain standards for data integrity and quality assurance
- Responsible for representing the provider network area on projects, reporting and tracking provider changes, or for the support, coordination, and production of the directory
- Basic knowledge of NCQA, CMS and State standards related to Provider Data Integrity
- Utilize database systems and tools to enter and / or research provider data (e.g., NDB; CSP Facets; PhyCon; CAQH; Impact; Navigator; Provider Loading and Maintenance Instructions [PLMI]; etc.)
6
Experience For Provider Data Specialist Resume
- Interpret, analyze, and / or update C&S State required data elements and provider record set - up within NDB and / or CSP Facets
- Review system results to determine whether keyed data is correct, or updates are necessary
- Use pertinent data and facts to identify and solve a range of problems within area of expertise (e.g. Missing or Incorrect Data Elements, Incorrect Provider Set - up, NDB to CSP Feed Error Resolution, etc.)
- Investigate, interpret, analyze and process non - standard requests and problems, often in form of special projects and ad - hoc requests
- Communicate directly with the Network Account Manager, the Contract Analysts and / or external partners to gain clarification tied to provider demographic and contractual data within NDB and / or CSP Facets, if needed
- Conduct a full system End to end review on provider installation and administration of assigned tasks
- Investigates and analyzes non - standard requests and problems, with some assistance from others
- Consistently meet target production, quality, and time utilization metrics
7
Experience For Senior Provider Data Specialist Resume
- Develop and maintain productive work relationships
- Process improvements (Identify and research feasibility)
- Provide personalized and consultative education and information
- Research, develop and present Root Cause analysis presentations to mid-level management (Supervisors / Managers)
- Solve moderately complex problems on your own
- Review customers and/or prospective customers’ geographic locations to recommend optimal network solutions
- Review RFP requirements and complete necessary reports and documentation to support recommended network solutions
8
Experience For Provider Data Specialist Resume
- Review and communicate as needed demographic and discount information needed to determine network recommendations within the team and with the sales team
- Sometimes act as a technical resource to others within our function
- Provide analytical support to the Network Administrators in preparing for customer presentations, new network reviews, and network recommendations surrounding non - standard RFP reviews
- Coordinates with management and other team members to develop answers to non - standard RFP questions
- Coordinate with sales functions to ensure network requests are completed within our standard timelines
- Able to work independently as well as a member of a team
9
Experience For Senior Provider Data Specialist Resume
- Perform data entry and use sort / filter option in Microsoft Excel
- Intermediate level of proficiency with Microsoft Word and Microsoft Excel (update and create spreadsheets)
- Intermediate level of proficiency with Microsoft Word and Microsoft Excel (update and create documents and spreadsheets)
- Intermediate level (or higher) of proficiency with Microsoft Word and Microsoft Excel
- Intermediate level of proficiency with MS Office, particularly in Excel
10
Experience For Provider Data Specialist Resume
- Basic knowledge of confidentiality and its requirements (i.e., HIPAA)
- Create, copy, edit, send, and save within MS Word
- Inventory queue management
- Provider data attestations
- Knowledge of NCQA standard
- Create, copy, edit, send, and save within Microsoft Word
List of Typical Skills For a Provider Data Specialist Resume
1
Skills For Senior Provider Data Specialist Resume
- Maintain multiple projects and priorities at one time and effectively finish projects in a timely manner
- Experience with MS Office including Access or other database equivalent
- Experience with provider data (demographic and / or contractual) including provider data load and / or maintenance, claims, or member assignment
- Experience in a role requiring in - depth research and / or analysis
- 1+ year of data entry experience
- 1+ year experience in the healthcare industry
- Professional office work experience
- NDB or CSP experience
- Experience in a professional office environment
2
Skills For Provider Data Specialist Resume
- Experience with Microsoft Word and Excel - basic navigation
- Provider Verification Outreach or health insurance industry experience
- Experience in the health care industry
- Claims / data entry experience
- Customer service and / or data entry experience preferably in the health care industry
- Provider data work experience
- 6+ months of experience in the healthcare industry
- Provider data directory experience
3
Skills For Senior Provider Data Specialist Resume
- Experience with platforms Emptoris, and Phycon or similar platforms
- Contract or demographic load experience
- Experience with CRM
- Experience in managing cross functional projects and making presentations
- Previous coaching / buddy experience
4
Skills For Provider Data Specialist Resume
- Experience with claims processing systems such as COSMOS, UNET, and / or CSP
- Experience in CSP Facets system
- Experience with provider data (demographic and / or contractual)
- Experience with quality programs and process improvement initiatives
- Experience in Provider Data Operations workflow tools (PhyCon, Navigator, etc.)
5
Skills For Senior Provider Data Specialist Resume
- Microsoft Excel experience (ability to filter, sort, create and edit spreadsheets)
- Experience in the health care industry
- Experience with Provider Networks’ practices, business processes and work standard
- Tracking data projects, organizing projects, managing task assignments
- Reporting and extracting data for various reports and analyses
- Coaching for productivity and quality (utilizing the 5 - why process)
- Working knowledge of Medi-Cal and/or managed care
- Maintaining current provider data to ensure the quality of the network
6
Skills For Provider Data Specialist Resume
- Identifying needed updates to documentation
- Intermediate level (or higher) of proficiency with Microsoft Excel (filtering, sorting, creating and editing)
- Provide guidance to internal functions regarding reporting capabilities surrounding network requests
- Proficiency within Microsoft Excel (Creating and editing documents)
- Data analysis, business analysis, reporting or auditing
- Basic knowledge of NCQA credentialing and re-credentialing standards
- Provide analytical support to the Network Specialists in reviewing and explaining renewal recommendations
- Supports business unit in updating and analyzing network demographic and claim information as needed
7
Skills For Senior Provider Data Specialist Resume
- Serve as administrator and super user of credentialing software and work with internal and external staff to utilize software
- Design and produce meaningful data reports for internal and external reporting
- A high drive toward problem solving and accountability
- Healthcare knowledge with the understanding of Medicare and Medicaid
- Develop reports using pivot tables and graphs within MS Excel
- Complete data entry using database tables within MS Access
- Develop reports using pivot tables and graphs within Microsoft Excel
8
Skills For Provider Data Specialist Resume
- Complete data entry using database tables within Microsoft Access
- Enter and update providers using Beacon’s proprietary FlexCare system
- Review multiple source systems and accurately determine credentialing completion, data load completion and client data feed completion
- Responsbile for maintaining data integrity and quality assurance
- Assist in the coordination of projects, including provider outreach, provider conversions, provider service area expansions and business expansion
- Participate in departmental and interdepartmental meeting as necessary
- Maintain professional growth and development through self directed learning activities
9
Skills For Senior Provider Data Specialist Resume
- Manage communication processes with other departments regarding database improvements
- Coordinate corrective activities to clean data and manage communication processes with other departments regarding data improvements
- Explain and answer questions related to our standard network reports supporting our recommended network solutions
- Basic level (or higher) of proficiency with MS Word and Excel
- Serve as project manager on projects related to automation of Provider Services activities
- Develop and maintain systematic workflows and policies & procedures to support the Provider Services department with staff trainings and quality assurance
- Train and audit staff on activities related to accuracy and maintenance of provider data
10
Skills For Provider Data Specialist Resume
- Ensure efficiency and accuracy in provider services processes with an emphasis on automation
- The ability to learn and execute processes and procedures
- A sense of urgency and accountability
- Intermediate level proficiency with Microsoft Word
- Create correspondence and work within templates in Microsoft Word
- The ability to create correspondence and work within templates in Microsoft Word
- The ability to perform data entry and use sort/filter option in Microsoft Excel
- Intermediate level of proficiency with Microsoft Word and Excel (update and create spreadsheets)
List of Typical Responsibilities For a Provider Data Specialist Resume
1
Responsibilities For Senior Provider Data Specialist Resume
- Utilize design view in Microsoft Access
- Proficiency within Microsoft Excel (Ability to create spreadsheets)
- Proficiency within Microsoft Word (Ability to create documents)
- Familiarity with provider demographic data
- Experience with Microsoft Word (creating, saving, formatting documents) Microsoft Excel (creating, saving, formatting spreadsheets) and Outlook (ability to open and send emails)
- Intermediate level of proficiency with MS Office - Microsoft Word (create correspondence and work within templates), Microsoft Excel (ability to sort, filter, and create simple spreadsheets), and Microsoft Outlook (email and calendar management)
- Intermediate level proficiency in tracking, trending and reporting on metrics
2
Responsibilities For Provider Data Specialist Resume
- Intermediate proficiency in Microsoft Office - Microsoft Word (create correspondence and work within templates), Microsoft Excel (ability to sort, filter, and create simple spreadsheets), and Microsoft Outlook (email and calendar management)
- Intermediate level of proficiency with Microsoft Excel with the ability to edit, create, save and send spreadsheets
- Intermediate level of proficiency with MS Excel with the ability to create and edit spreadsheets
- Proficiency in MS Access with the ability to create and edit spreadsheets
- Communication (written, verbal and listening), project management, interpersonal, comprehension, problem solving, analytical, research, prioritization, data management and implementation skills
- Understand all credentialing activities performed within assigned areas including product specific credentialing and approaches, with an emphasis on operational efficiency and quality optimization
3
Responsibilities For Senior Provider Data Specialist Resume
- Understand group adds, terminations and changes received directly from groups in organizational systems
- Grasp technical details and communicate technical requirements to staff
- Proficiency with a keyboard and a 10 key
- Intermediate knowledge of MS Word and Excel or other similar software applications
- Applies knowledge of business requirements and provider needs to build provider profile and maintain provider records for all changes to practitioner status including: provider set up, demographic changes, network expansion, additional products and additional data required by state regulations, NCQA and validating the information has been entered and set-up correctly in multiple systems
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