Provider File Specialist II

Description

Logistics: Palmetto GBA, – one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: Full-time (40-hours/week) Monday-Friday in a typical office environment. Scheduled during normal business hours of 8:00AM-5:00PM. Occasional overtime may be required. Role located at 17 Technology Circle, Columbia, SC, 29203.
Government Clearance: Requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.
SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. Coverage begins on the first day of the month following 28 days of full-time employment.

To Qualify For This Position, You'll Need The Following Required Education And Experience

• High School Diploma or equivalent
• 3 years of experience in customer service, claims processing, and/or provider network certification, or combination

Required Software And Tools

• Microsoft Office
• Working knowledge of DB2 or other database software

Required Skills And Abilities

• Working knowledge of word processing, spreadsheet, and database software
• In-depth knowledge of provider certification process, claims processing operations/systems
• In-depth knowledge of pricing methodology and discount programs
• Good judgment skills
• Demonstrated verbal and written communication skills
• Demonstrated proficiency in spelling, punctuation, and grammar skills
• Basic business math proficiency and knowledge of mathematical or statistical concepts
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion

What You’ll Do

• Obtains necessary information (written notifications, faxes, emails, or telephone contacts) and establishes certification of healthcare service providers.
• Prepares provider files/maintains provider data (updates, additions, deletions) on the provider information management system (PIMS) or appropriate provider systems/database.
• Generates and analyzes various provider reports to management.
• Affords technical support through system testing to ensure system enhancements/modifications.
• Researches/resolves issues/problems from providers related to eligibility, recertifications, edits, billing, etc.
• Contributes to department's production standard by working on PIMS and AMMS (automated medical management systems) or appropriate provider system/database maintenance/error reports.
• Contributes to and participates on special projects, which may include but are not limited to the following: mass rate updates, quality improvement, audits, etc.