Provider Configuration Specialist in Orange at Prospect Medical Systems

Date Posted: 8/15/2019

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    600 City Parkway West
    Orange
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    8/15/2019
  • Job ID:
    13320

Job Description



Provider Configuration Specialist

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

This position is responsible for maintaining provider dictionaries, vendor contracts, fee schedules and capitation agreements in the managed care system. The position is responsible for the daily operational activities which will ensure successful and accurate claims and capitation payment to various contracted or non-contracted entities. Position is a liaison to Provider Contracting, Claims, Provider Dispute Resolution, and Claims Recovery regarding claims or capitation payment issues.



Job Responsibilities/Duties

  • Update and maintain IDX Provider dictionaries from multiple sources such as contracting change forms, return mail and claims received from vendors not in IDX. All updates to be made with a high degree of accuracy and speed.
  • Update and maintain Vendor Contracts; custom fee schedules and capitation agreements 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. All updates to be made with a high degree of accuracy and speed.
  • Update and maintain Medicare fee schedules from CMS and CMS carrier web-sites. Update and maintain Medicaid fee schedules from Medicaid web-site.
  • Manage and resolve timely claim queues for Provider edits (PVA - Pend Vendor Add) or Fee Schedule/rate inquiries (PFS - Pend Fee Schedule) by making appropriate updates in IDX. Manage and resolve timely Change Forms received from Provider Contracting for new or amended contracts by making appropriate updates in IDX.
  • Assist in completion of major projects.  Define, develop, drive and deliver assigned small projects. Assist with training new hires.


Qualifications

Minimum Education: High School degree or Associate preferred. 

Minimum Experience: Thorough understanding of ICD-10, 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. 



Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol.  Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm.  For this reason, we require applicants to pass a screening for drug use as a condition of employment.  This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.



How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm



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