Sr. Contract Configuration Specialist - Prospect Medical Holdings, Inc.
Orange, CA 92856
About the Job
Minimum Experience: Thorough understanding of ICD-9, CPT and HCPCS codes. Thorough understanding of Medicare and Medi-Cal fee schedules, RVUs and ASA reimbursement. Knowledge of medical terminology. Ability to read and interpret contracts and/or contract summaries. Knowledge of SQL, data structures or a programming language. Experience with IDX preferred. Minimum 2-3 years of related experience. Proficient in Windows environment with Microsoft Office Suite, including Word, Excel, and Access, Adobe. Proficient with Microsoft Outlook or other E-mail and scheduling products. Knowledge of basic Internet terminology and functionality.
Req. Certification/Licensure: None.
"Location-Based Pay Adjustment"
- Create and maintain provider dictionaries, custom fee schedules, vendor contracts and capitation based on contract terms. 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 capitation schedules and assign capitation rates for capitated Primary Care and Specialist providers. Test claims to make sure claims are being processed correctly as per the contract terms. Maintain Medicare and Medicaid fee schedules. Create and maintain all appropriate logs for fee schedules and capitation agreements.
- Process PVA/PVAS and PFS claims within stated Service Level Agreements by making appropriate updates to provider dictionaries, vendor contracts and fee schedules.
- Create and support new and existing DBMS reports. Analyzes root cause of errors; communicates errors to the appropriate clients and escalates IDX errors, issues, or problems to the Business Unit Manager. Assists in the research and evaluation of additional IDX capabilities required in support of clients needs.
- Lead and mentor junior Contract Configuration Specialists and foster development of skills and knowledge. Support and participate in on-boarding and training of new Contract Configuration Specialists. Take responsibility for developing, managing & completing projects.
- Create and maintain provider dictionaries, custom fee schedules, vendor contracts and capitation based on contract terms. 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 capitation schedules and assign capitation rates for capitated Primary Care and Specialist providers. Test claims to make sure claims are being processed correctly as per the contract terms. Maintain Medicare and Medicaid fee schedules. Create and maintain all appropriate logs for fee schedules and capitation agreements.
- Process PVA/PVAS and PFS claims within stated Service Level Agreements by making appropriate updates to provider dictionaries, vendor contracts and fee schedules.
- Create and support new and existing DBMS reports. Analyzes root cause of errors; communicates errors to the appropriate clients and escalates IDX errors, issues, or problems to the Business Unit Manager. Assists in the research and evaluation of additional IDX capabilities required in support of clients needs.
- Lead and mentor junior Contract Configuration Specialists and foster development of skills and knowledge. Support and participate in on-boarding and training of new Contract Configuration Specialists. Take responsibility for developing, managing & completing projects.