Network Data Specialist I
Position Summary
The Network Data Specialist is responsible for the accurate and timely loading, maintenance, and validation of provider data. This role ensures that both participating and non-participating providers are correctly configured in claims and provider systems to support accurate claims adjudication, network management, and regulatory compliance. The Specialist partners closely with Provider Relations, Credentialing, and Claims teams to ensure provider data integrity and support monthly provider roster management and system synchronization across multiple platforms.
Key Responsibilities
Load contracted (participating) providers into provider and claims systems in accordance with executed provider agreements and configuration requirements.
Load and maintain non-participating provider records to ensure accurate claims processing and pricing.
Maintain accurate, complete, and up-to-date provider data across all claims and provider databases.
Provider Data Management
Ensure integrity of critical provider information including: Provider demographics, Tax ID and billing information, Specialty and taxonomy codes, Network participation status, Contract effective dates and terms.
Validate provider data accuracy prior to system loading and ongoing updates.
Apply business rules and system requirements to ensure proper configuration across all downstream applications.
System Maintenance & Data Synchronization
Synchronize provider data across multiple claims, provider, and configuration systems.
Ensure consistency of provider information across enterprise platforms.
Identify and resolve data discrepancies between systems and source documentation.
Support updates to provider files based on contracting, credentialing, or network changes.
Provider Relations & Credentialing
Partner with Provider Relations to support onboarding, updates, and maintenance of contracted providers.
Work closely with Credentialing teams to ensure only appropriately credentialed providers are loaded and active in systems.
Validate credentialing status and ensure alignment with network participation requirements prior to system activation.
Support resolution of provider data issues identified by internal stakeholders or external providers.
Non-Participating Provider Configuration
Load and maintain non-participating provider records to ensure accurate claims routing and pricing logic.
Ensure non-participating provider data supports correct claims adjudication and out-of-network processing rules.
Maintain accurate classification of provider participation status across systems.
Provider Rosters & Reporting
Manage monthly provider roster updates, including additions, terminations, and changes.
Reconcile provider rosters received from external sources against internal systems.
Validate and distribute provider roster files to appropriate internal stakeholders.
Support reporting needs related to provider network composition and data accuracy.
Quality Assurance & Compliance
Validate provider data against contractual requirements, network standards, and system specifications.
Ensure compliance with internal policies and regulatory requirements related to provider data management.
Maintain audit-ready documentation of provider data changes and updates.
Support internal and external audits by providing accurate provider data records.
Qualifications & Education
High School Diploma or GED required.
Minimum of 3 years of experience in healthcare provider data management, claims systems, credentialing support, or managed care operations.
Experience working with provider databases, claims systems, or network configuration tools.
Equivalent combination of education and experience may be considered.
Preferred Qualifications
Experience in managed care health plan or health insurance environment.
Familiarity with provider credentialing and contracting processes.
Understanding of provider taxonomy, NPI, and healthcare provider identifiers.
Experience managing provider rosters or large-scale data files.
Knowledge of claims adjudication systems and network configuration rules.
Skills & Competencies
Strong attention to detail and data accuracy.
Ability to manage large volumes of provider data efficiently.
Strong analytical and problem-solving skills.
Understanding of healthcare provider data structures and systems.
Ability to collaborate effectively with cross-functional teams.
Strong organizational and time management skills.
Ability to work independently in a production-driven environment.
Additional Notes
The Network Data Specialist plays a critical role in ensuring the accuracy and integrity of provider data across the health plan's systems. This position directly impacts claims accuracy, provider payment integrity, and network operations by ensuring providers are correctly loaded, maintained, and aligned with contractual and credentialing requirements.
WORK CONDITIONS
The noise level in the work environment is usually moderate.
Fast-paced office environment.
Highly regulated environment.
Time frames to handle issues are in accordance with CMS time frames.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds.
While performing the duties of this job, the employee is regularly required to talk or hear.
The employee is frequently required to stand and walk.
The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl.
Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.