Provider Data Representative

The Provider Data Representative ensures complete, accurate, and timely provider demographic, participation, credentialing, enrollment, roster, and directory information across systems supporting the World Trade Center Health Program (WTCHP). The role safeguards 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 comprehensive, correct, and aligned with program and organizational standards.

Key Responsibilities:

Directory Accuracy & Completeness

• Maintain high accuracy standards for provider directory data.
• Support issue resolution that reduces member and provider complaints arising from directory discrepancies.

Timely Updates & Maintenance

• Process demographic changes, additions, terminations, and updates within service‑level expectations.
• Reduce backlog and improve turnaround time through efficient workflow management.

Data Integrity Management

• Validate and maintain NPIs, TINs, specialties, practice locations, affiliations, licensure, and EFT data.
• Identify and reduce claims‑impacting data error rates; support audit readiness.

Roster Reconciliation

• Reconcile provider rosters against credentialing, enrollment, claims, and directory systems.
• Identify discrepancies affecting participation or claims payment and coordinate timely correction with cross‑functional teams.

Credentialing & Enrollment Support

• Validate provider demographic data required for onboarding, credentialing, and recredentialing.
• Identify and resolve participation or enrollment inconsistencies to ensure timely activation.

Claims & Operational Support

• Identify data issues impacting claims adjudication, reimbursement, or provider participation.
• Partner with Claims Operations to resolve discrepancies and support root‑cause analysis.

Reporting & Analytics

• Generate dashboards, productivity logs, discrepancy reports, and data quality metrics.
• Track turnaround times, accuracy rates, and productivity; provide insights to leadership for continuous improvement.

Provider & Stakeholder Communication

• Communicate data requirements, corrections, and discrepancies to credentialing, enrollment, and provider relations teams.
• Maintain clear documentation supporting provider updates and operational workflows.

Process Improvement & Tooling

• Recommend workflow enhancements, automation opportunities, and system updates.
• Support implementation of new tools, templates, and operational processes.

Required Qualifications

• Bachelor’s degree preferred.
• 3+ years of experience in provider data, credentialing, enrollment, or health plan operations.
• Strong analytical skills and proficiency in Microsoft Excel.
• Exceptional attention to detail and accuracy.

Preferred Qualifications

• Experience supporting federal or government‑sponsored healthcare programs.
• Knowledge of provider directory regulatory requirements and healthcare data standards.
• Experience with provider portals, enrollment systems, or enterprise provider data platforms.

Skills & Attributes for Success

• Data governance and quality management
• Analytical thinking and problem solving
• Process improvement mindset
• Attention to detail
• Strong written and verbal communication
• Collaboration and teamwork

GDIT IS YOUR PLACE:

• Full-flex work week to own your priorities at work and at home.
• 401K with company match.
• Comprehensive health and wellness packages.
• Internal mobility team dedicated to helping you own your career.
• Professional growth opportunities including paid education and certifications.
• Cutting-edge technology you can learn from.
• Rest and recharge with paid vacation and holidays.

#GDITFedHealthJobs

#GDITWTCJobs