Provider Relations Coordinator

Job Title:  Provider Relations Coordinator

Job Code:  N01716

Grade Level:  21

FLSA Status:  Non-Exempt

Department:  Provider Relations

Reports To:  Provider Relations Operations Supervisor

Last Updated:  December 2024

Position Summary:

The primary responsibility of the Provider Relations Coordinator is to create and maintain Provider records in the enterprise and NPF systems.  This process includes all updates related to 1099 records and the credentialling process.  This position provides customer support for Providers to ensure appropriate processing of claims and communicates with Providers and PR Representatives with updates and findings.

Essential Functions and Job Responsibilities:

1. Creates and maintains Provider network data.  This work may include but is not limited to:

• Entering data for new providers in the enterprise system and NPF;

• Ensuring accuracy of external validation process through the IRS, NPPES, NPDB, OIG and MLB (sanction) websites;

• Reviewing contracts and new Credentialing Profile to ensure completeness and accuracy.

• Processing Provider record changes (TIN, W9, name, address, credentialing, program contracting, specialty, fee schedule, NPI and participating provider status

• Investigate and Re-mail Returned Mail, including checks and provider newsletters;

• Updating necessary address corrections in the enterprise system and NPF.

2. Ensure accurate completion of the credentialing and recredentialing process.  This work may include but is not limited to:

• Gathering necessary documentation from providers to ensure compliance with regulatory and contractual requirements;

• Accessing the National Provider database to verify information;

• Reviewing provider applications for accuracy and completeness;

• Following up with Providers for additional information as required;

• Creating and maintaining provider files and records and renewals;

• Initiating the recredentialing process as necessary;

• Ensuring all network participants are credentialed in the timeframe required.

3. Maintaining the integrity of NPF data and conduct the NPF Administrator functions.  This work includes but is not limited to:

• Reviewing daily and monthly NPF error reports;

• Resolving issues identified with NFP data;

• Monitoring compliance with NPF participation;

• Updating NPF records as needed.

4. Researches and resolves issues impacting claims processing.  This work includes but is not limited to:

• Updating Provider data to ensure appropriate processing of existing claims;

• Assisting and resolving provider and claims issues identified by Customer Service;

• Gathering accurate information for claims processing including address and fee issues, NPI numbers not on file, missing or incorrect provider information, etc.

• Processing the set up and maintenance of EFT information in the enterprise system and the NPF for Providers requesting to receive claims payments electronically.

5. Communicates with Providers and PR Representatives in a professional manner.  This work may include but is not limited to:

• Providing professional and consistent updates on Provider updates, claims and open issues;

• Contacting Providers to provide responses to questions and solutions to issues;

• Collaborating with PR Representatives to ensure strong communication for shared accounts;

• Responding to calls and emails within a timely manner to ensure a positive client experience.

6. Performs processes related to 1099 records. This work may include but is not limited to:

• Maintaining Provider W-9 Records and filings;

• Validating claims payment dollars, tax id numbers and identification of entity names.

Regular and reliable attendance is required.

Other duties and responsibilities may be assigned.

Qualifications:

• 3 years’ experience in the dental industry or claims processing role preferred;

• Knowledge and experience in benefit determination and dental terminology preferred;

• Strong verbal and written communication skills;

• Detail-oriented with a commitment to accurate and efficient claims processing.

Competencies:

• Communication

• Critical Thinking

• Detail Orientation

• Drive for Results

• Organizational Skills

• Process Orientation

• Quality Focused

• Resourcefulness

Environment:

This position currently functions as a hybrid role working from both home and in-office environments.  Any home office setting must be conducive to all guidelines outlined by the organization.  This role is required to regularly attend in-person meetings, the frequency of which is determined by management based on departmental or organizational needs.  

Physical and Other Demands:

Specific vision abilities required by this job include the ability to adjust focus.  While performing the duties of this job, the employee is regularly required to sit, talk and hear.  The employee is frequently required to use hands and arms to handle, feel, reach and operate a computer.  This job requires substantial typing.

DDMO provides reasonable accommodation to qualified individuals with a known disability unless doing so imposes an undue hardship.  

Employees must be able to successfully perform the essential functions of this role with or without a reasonable accommodation.

Disclaimer:

This job description is designed to provide a general overview of the requirements of the job and does not entail a comprehensive listing of all activities, duties or responsibilities that will be required.  The organization reserves the right to modify this job description at any time; including assigning or reassigning job duties or deleting this position at any time.