Quality control of Credentialing files, Provider Maintenance, and Provider Contracting.Perform analysis to recommend and implement process improvements related to the efficiency and accuracy of the Provider file.Serve as a resource and educator for all Provider Information Management teams.Ensure compliance with National Committee on Quality Assurance (NCQA), CMS, DOH regulations, BCBS, internal and private business audits in the provider data management space.Collaborate with the Compliance team on audit data, providing required updates to process documentation.Analyze and resolve problems related to provider file setup, provider affiliations, reporting, data inputs and outputs, and subsequent requirements.Internally audit high complexity work items within the Provider file department.High Performer award 2022

Supported the sales team, ensuring detailed information was properly coded and entered accurately into the Highmark system. Performed analysis by interpreting medical benefit data from diverse sources and utilizing knowledge of moderate to complex business rules.

Ensured data integrity and accurate distribution of provider demographic data to and from Network Management systems and databases. Analysed and evaluated accuracy of provider data received from external sources and link to a provider record. Reviewed provider maintenance requests for complete information and maintained all provider data in support of claim adjudication and production of directories.

Earned a promotion to process Medicare Appeal claims. Processed and manually adjusted 20 claims daily, researched and applied voluntary refunds received from providers and beneficiaries, and handled delinquent debt follow-up, including debt referral to Treasury. Established accounts receivable and issued demand letters, tracked data for financial reporting purposes, and gathered information to determine appropriate provider billing.