Full-time, Part-time

Assonet, MA 02702

Under direction of the Supervisor, Provider Operations, the Provider Operations Specialist is responsible for a broad range of NCPM activities for Provider Information, Provider Credentialing, Allied Health and NCPM as required. The Provider Operations Specialist reviews and assists in the development of processes for both new initiatives as well as reviewing existing processes. The Provider Operations Specialist assists others in the team and participates in training as needed as well as reviewing work for data integrity issues. The Provider Operations Specialist actively participates in process redesign work, developing end-to-end process flows, documenting new work flows for all core systems such as TAHPMASTER, DIAMOND, ALUI, Health Rules Payor, and CACTUS to maintain, revise or supplement information in all databases for all THP products/plans.  The candidate communicates with both internal and external customers by telephone, email and facsimile and in writing regarding provider information. This position is able to perform many of the functions within each area to ensure data integrity across the department and to be an additional resource to the entire department needs on an “as needed” basis, as well as participating in special projects.  

The department is the business owner enterprise-wide for all lines of Tufts Health Plan’s   provider network data systems and the candidate must be knowledgeable and familiar with the data content to ensure accurate entry.  Data integrity is critical to ensure efficient claims processing, creation of accurate provider and member directories and mailings, and reliability of customer servicing information.

The Provider Operations Specialist interacts with the following (this is not intended to be a comprehensive list): externally to doctors and allied providers, internally to claims operations, provider and member customer relations, allied health services, credentialing, appeals and grievances, and contracting. Participation in process redesign work is an important element of this position along with applicable documentation.

Job Description

Key Responsibilities/Duties – what you will be doing 

  • Responsible for inputting and maintaining provider data for multiple systems e.g., Service Now, TAHPMaster, Diamond, ALUI, Health Rules Payor and Cactus including updates, corrections, adds, terms
  • Responsible for receiving, translating and triage for all provider information adds, changes and requests in accordance with Tufts and Public Plans policy and procedure’s.
  • NPI Updates and out of network ID creation support Receive and ensure timely response to inquiries, phone calls, emails, and websites..
  • Collaborate with all areas within NCPM including Credentialing Department, Provider Information, and Provider Operations, as needed.
  • Collaborate between external provider representatives, internal stakeholders and providers to respond to data integrity analysis related to provider data.
  • Assists with process review, design, development and documentation for all support areas on an on-going basis
  • Execute special projects relating to data integrity and other special projects as assigned.

Qualifications – what you need to perform the job 

  • B.A./B.S. or equivalent in health care or related field preferred.
  • 3+ years experience in health care field. 
  • Experience with computers required. 
  • Experience in database management systems preferred. 
  • Knowledge of Windows, Microsoft Word, Excel preferred.
  • Process improvement and data management experience preferred.
  • Must have the ability to maintain and manipulate a complex provider database.  Must be able to prioritize multiple tasks and achieve deadlines.  Must have ability to adapt to a changing environment.  The position requires the ability to analyze and understand complex payment issues and plan operational concerns.  Strong written and verbal skills are necessary.  Individual must possess initiative, judgment, exceptional organizational skills as well as a keen attention to detail.
  • Must have excellent verbal and written communication skills.
  • Must be able to work cooperatively as a team member. Frequent contact, both written and verbal, with practitioners, office staff, billing agents and internal customers.  Must use discretion when dealing with Plan providers and all other departments.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

About Us:

Point32Health is a leading health and wellbeing organization, delivering an ever-better health care experience to everyone in our communities. Building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

At Point32Health, we’re working to reshape the world of health care by pushing past the status quo and delivering even more to the diverse communities we serve: more innovation, more access, more support, and healthier lives. And we want people like you on our side to make it even better.

This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R4811

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Posting ID: 777955243 Posted: 2023-02-04 Job Title: Provider Operation Specialist