Operations Resolution Specialist

Title: Operations Resolution Specialist

MCHP – Provider Data Management remote

Location: Mount Carmel Corporate Services Center

Job Description:

Employment Type:

Full time

Shift:

Description:

This is a temporary, full‑time position with an expected duration of 3 months

Why MediGold?           

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing. 

Position Purpose:

Provider Data Management role manages the integrity of the Health Plan's provider data to maintain compliance with Federal and local requirements. This position must have knowledge and competence in regulatory requirements for the Health Plan's provider data while maintaining confidentiality and use of discretionary discernment with sensitive materials. Serves as department subject matter expert requiring knowledge of plan systems, tools, policies and procedures and acts as liaison with internal and external customers. The role will conduct audits to ensure compliance with the Centers for Medicaid and Medicaid Services (CMS) requirements. Additionally, the role will be expected to produce accurate reports of the plan's provider data as required by CMS for HEDIS purposes. The ORS-Provider Data Management role will be responsible for identification of root causes regarding any discrepancies found in the provider data while working alongside all other Operations Resolution Specialists across the plan to fully resolve issues

What you will do:

• Preparation of all initial direct and delegated credentialing rosters for automated Provider Data Load (PDL) process

• · Process rejection reports from PDL process and correct any errors discovered

• · Education of CIN, groups, etc. for future expansion regarding direct and delegated roster formats to ensure accurate PDL

• · Internal audit (monitoring) of Provider Data, such as demographic changes, TIN adds, provider terms, etc

Minimum Qualifications:

• Education: Associate or Bachelor’s degree preferred.

• · Certification: N/A

• · Experience: One to three years experience preferred in either managed care health insurance.

• · Effective Communication Skills.

• · Strong written and verbal communication skills in order to communicate in clear, concise terms to internal and external customer.

• · Analytical and problem-solving skills.

• · Experience in use of computer systems and office automation applications.

• · Knowledgeable with provider credentialing and contracting terminology.

• · Basic knowledge of healthcare claims process.

Ministry/Facility Information:

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.