Network Data Specialist I

The Network Data Specialist is responsible for the accurate and timely loading, maintenance, and validation of provider data. This role ensures that both participating and non-participating providers are correctly configured in claims and provider systems to support accurate claims adjudication, network management, and regulatory compliance.

The Specialist partners closely with Provider Relations, Credentialing, and Claims teams to ensure provider data integrity and support monthly provider roster management and system synchronization across multiple platforms., * Load contracted (participating) providers into provider and claims systems in accordance with executed provider agreements and configuration requirements.

• Load and maintain non-participating provider records to ensure accurate claims processing and pricing.
• Maintain accurate, complete, and up-to-date provider data across all claims and provider databases.

Provider Data Management

• Ensure integrity of critical provider information including:

• Provider demographics
• Tax ID and billing information
• Specialty and taxonomy codes
• Network participation status
• Contract effective dates and terms

• Validate provider data accuracy prior to system loading and ongoing updates.
• Apply business rules and system requirements to ensure proper configuration across all downstream applications.

System Maintenance & Data Synchronization

• Synchronize provider data across multiple claims, provider, and configuration systems.
• Ensure consistency of provider information across enterprise platforms.
• Identify and resolve data discrepancies between systems and source documentation.
• Support updates to provider files based on contracting, credentialing, or network changes.

Provider Relations & Credentialing Collaboration

• Partner with Provider Relations to support onboarding, updates, and maintenance of contracted providers.
• Work closely with Credentialing teams to ensure only appropriately credentialed providers are loaded and active in systems.
• Validate credentialing status and ensure alignment with network participation requirements prior to system activation.
• Support resolution of provider data issues identified by internal stakeholders or external providers.

Non-Participating Provider Configuration

• Load and maintain non-par provider records to ensure accurate claims routing and pricing logic.
• Ensure non-participating provider data supports correct claims adjudication and out-of-network processing rules.
• Maintain accurate classification of provider participation status across systems.

Provider Rosters & Reporting

• Manage monthly provider roster updates, including additions, terminations, and changes.
• Reconcile provider rosters received from external sources against internal systems.
• Validate and distribute provider roster files to appropriate internal stakeholders.
• Support reporting needs related to provider network composition and data accuracy.

Quality Assurance & Compliance

• Validate provider data against contractual requirements, network standards, and system specifications.
• Ensure compliance with internal policies and regulatory requirements related to provider data management.
• Maintain audit-ready documentation of provider data changes and updates.
• Support internal and external audits by providing accurate provider data records., The Network Data Specialist plays a critical role in ensuring the accuracy and integrity of provider data across the health plan's systems. This position directly impacts claims accuracy, provider payment integrity, and network operations by ensuring providers are correctly loaded, maintained, and aligned with contractual and credentialing requirements.

Do you have experience in Time management?, Do you have a High school diploma or GED?, To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions., * High School Diploma or GED required.

• Minimum of 3 years of experience in healthcare provider data management, claims systems, credentialing support, or managed care operations.
• Experience working with provider databases, claims systems, or network configuration tools.
• Equivalent combination of education and experience may be considered., * Experience in managed care health plan or health insurance environment.
• Familiarity with provider credentialing and contracting processes.
• Understanding of provider taxonomy, NPI, and healthcare provider identifiers.
• Experience managing provider rosters or large-scale data files.
• Knowledge of claims adjudication systems and network configuration rules.

Skills & Competencies

• Strong attention to detail and data accuracy
• Ability to manage large volumes of provider data efficiently
• Strong analytical and problem-solving skills
• Understanding of healthcare provider data structures and systems
• Ability to collaborate effectively with cross-functional teams
• Strong organizational and time management skills
• Ability to work independently in a production-driven environment, This Job Description may be modified at any time at the discretion of the employer as business operation may seem necessary. This does not constitute an employment agreement and may not include all duties. The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Time frames to handle issues are in accordance with CMS time frames.

This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours.