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The Provider Data Representative maintains accurate provider demographic, participation, credentialing, enrollment, roster, and directory information across all systems supporting the World Trade Center Health Program (WTCHP).
The role ensures provider data integrity to support accurate claims payment, credentialing compliance, provider directory accuracy, and network participation. The Representative partners with Provider Relations, Credentialing, Provider Data, Claims Operations, and Contracting to keep provider information complete, accurate, timely, and compliant with organizational standards.
Key Outcomes & Success Metrics
- Directory accuracy & completeness: Meet internal standards and regulatory expectations; reduce member/provider complaints due to directory errors.
- Maintenance timeliness: Process updates, additions, terminations, and changes within SLAs; reduce cycle time and backlog.
- Data integrity: Improve audit scores; lower claims‑impacting data error rates; maintain accurate NPIs, TINs, specialties, practice locations, affiliations, licenses, and EFT details.
- Roster reconciliation effectiveness: Validate rosters against credentialing, enrollment, terms & conditions, claims, and directory data; correct discrepancies promptly.
- Credentialing & enrollment support: Ensure data readiness for onboarding and recredentialing; reduce participation activation delays.
- Operational reporting: Provide clear dashboards and logs for productivity, turnaround times, accuracy, and issue remediation.
Essential Duties & Responsibilities
Data Intake & Maintenance Operations
- Process provider roster submissions and updates.
- Maintain accurate provider demographic, enrollment, and participation records.
- Validate and update NPIs, TINs, specialties, practice locations, EFT details, and affiliations.
- Ensure timely changes supporting accurate claims payment and directory publication.
Roster Reconciliation
- Reconcile provider rosters against credentialing, claims, enrollment, and directory systems.
- Identify discrepancies impacting participation, claims payment, or directory accuracy.
- Coordinate corrections with Provider Relations, Credentialing, and Provider Data teams.
Credentialing & Enrollment Support
- Validate provider demographic information for credentialing/recredentialing.
- Identify and resolve enrollment and participation discrepancies.
- Ensure data requirements are complete for onboarding and participation activation.
Data Quality & Governance
- Audit provider records for completeness, accuracy, and compliance.
- Monitor directory accuracy, quality scores, and claims‑impacting error rates.
- Support development of data standards, QA programs, and process improvements.
Claims & Operational Support
- Identify provider data issues affecting claims adjudication, reimbursement, and participation.
- Collaborate with Claims Operations to resolve data discrepancies; support root‑cause analysis and remediation.
Reporting & Analytics
- Produce provider data quality reports, discrepancy logs, and audit results.
- Track maintenance productivity, turnaround times, and accuracy metrics.
- Provide insights to leadership to guide operational improvements.
Provider & Stakeholder Communication
- Communicate data requirements and discrepancies to credentialing, enrollment, and provider relations teams.
- Provide clear documentation for provider updates and requests.
Process Improvement & Tooling
- Recommend system enhancements, automation opportunities, and updated workflows.
- Support implementation of new processes, templates, and operational tools.
