Rates Configuration Specialist

Summary

Under the general direction of the Provider Database Management & Rates Configuration, Sr Supervisor, the Rates Configuration Specialist is responsible for creating, updating and maintaining provider dictionaries, vendor contracts, fee schedules, reading and interpreting contracts and/or contract summaries, and assigning fee schedules to providers. Should also be able to create reports relating to Vendor Contracts, Fee Schedules or Dictionaries for audit needs and ongoing rate evaluation, monitoring and testing. Responsible for the accuracy of system set up for adjudication of claims based on contractual language and rate terms.

Duties and Responsibilities:

• Create and maintain provider dictionaries and custom fee schedules based on contract terms
• Maintain Medicare and Medicaid fee schedules
• Assign the appropriate fee schedules to providers including writing and determining hierarchy of conditions and exceptions to the primary fee schedule based on the terms of the provider's contract
• Build and maintain all appropriate logs for fee schedules and fee set assignment implementation
• Auditing of EZ-CAP Providers/Vendor configuration (fee schedule, fee set assignments, etc.)
• Analyzes root cause of errors; communicates errors to the appropriate MPM stakeholders and escalates EZ-CAP errors, issues, or problems to the department leadership and HIT teams
• Assist PNO Network Management team and Field Representatives with provider concerns
• Interface with Benefits team and Claims team with questions/issues regarding provider configuration and reimbursement
• Conduct per diem reporting, analysis and requests
• Special projects, as needed

Minimum Job Requirements:

• 3+ years of Managed Care or Healthcare experience in Rate Configuration, Terms and Conditions, Reimbursement or Claims Auditing field
• EZ-CAP knowledge and experience required
• Thorough understanding of ICD-9, CPT and HCPCS codes, Medicare and Medi-Cal fee schedules, RVUs and ASA reimbursement
• Advanced knowledge of medical terminology and ability to read and interpret contracts and/or contract summaries
• Intermediate Proficiency in Microsoft Office Suite (Access, Word, Excel, PowerPoint, Outlook), Crystal Reports, SQL
• Substantive knowledge of basic Internet terminology and functionality

Skills and Abilities:

• Strong and consistent customer service acumen with the ability to resolve complaints and concerns
• Excellent attention to detail, with the ability to communicate and document information accurately
• Proven ability to effectively analyze information and think critically
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives
• Willingness take on and lead projects outside the normal scope of the job description

Salary Range:

• $70,000 - $77,500 annually