Provider Relations Coordinator

Job Title:  Provider Relations Coordinator

Job Code:  N01716

Grade Level:  21

FLSA Status:  Non-Exempt

Department:  Provider Relations

Reports To:  Provider Relations Operations Supervisor

Last Updated:  December 2024

Position Summary:

The primary responsibility of the Provider Relations Coordinator is to create and maintain Provider records in the enterprise and NPF systems.  This process includes all updates related to 1099 records and the credentialling process.  This position provides customer support for Providers to ensure appropriate processing of claims and communicates with Providers and PR Representatives with updates and findings.

Essential Functions and Job Responsibilities:

1.

Creates and maintains Provider network data.  This work may include but is not limited to:

• Entering data for new providers in the enterprise system and NPF;

• Ensuring accuracy of external validation process through the IRS, NPPES, NPDB, OIG and MLB (sanction) websites;

• Reviewing contracts and new Credentialing Profile to ensure completeness and accuracy.

• Processing Provider record changes (TIN, W9, name, address, credentialing, program contracting, specialty, fee schedule, NPI and participating provider status

• Investigate and Re-mail Returned Mail, including checks and provider newsletters;

• Updating necessary address corrections in the enterprise system and NPF.

 

2.

Ensure accurate completion of the credentialing and recredentialing process.  This work may include but is not limited to:

• Gathering necessary documentation from providers to ensure compliance with regulatory and contractual requirements;

• Accessing the National Provider database to verify information;

• Reviewing provider applications for accuracy and completeness;

• Following up with Providers for additional information as required;

• Creating and maintaining provider files and records and renewals;

• Initiating the recredentialing process as necessary;

• Ensuring all network participants are credentialed in the timeframe required.

 

3.

Maintaining the integrity of NPF data and conduct the NPF Administrator functions.  This work includes but is not limited to:

• Reviewing daily and monthly NPF error reports;

• Resolving issues identified with NFP data;

• Monitoring compliance with NPF participation;

• Updating NPF records as needed.

 

4.

Researches and resolves issues impacting claims processing.  This work includes but is not limited to:

• Updating Provider data to ensure appropriate processing of existing claims;

• Assisting and resolving provider and claims issues identified by Customer Service;

• Gathering accurate information for claims processing including address and fee issues, NPI numbers not on file, missing or incorrect provider information, etc.

• Processing the set up and maintenance of EFT information in the enterprise system and the NPF for Providers requesting to receive...