Responsibilities:

• Provide business and technical expertise for the system configuration of provider contracts, fee- schedules, claim rules and other related processes to achieve operational requirements.
• Perform system testing, analysis and complex problem solving related to provider configurations; make recommendations for improvements.
• Manage and monitor completion of periodic code updates (e.g., ICD-10, CPT, HCPCS), provider contracts annual updates (e.g., yearly rate escalators), Medicare fee schedules, DRGs, etc.
• Maintain provider data integrity and compliance; develop reports as required.
• Perform audits of configuration work.
• Support Provider Directory.
• Participate in meetings with decision-makers, systems owners, and end users to define business and operations requirements.
• Perform application administration, configuration, support, and maintenance duties.
• Provide orientation and training to end users.
• Develop and maintain Policies & Procedures.
• Communicate with internal departments as needed; advises the Claims Dept., Network Development, Provider Relations and Provider Inquiry Unit on provider configuration issues.
• Meet performance goals as established for the position.
• Performs additional duties and responsibilities as assigned by management.

Qualifications:

• Bachelor’s degree preferred.
• Experience in Medicare Advantage Plan, managed care or healthcare environment at large.
• In-depth knowledge of provider contracts, reimbursement methodologies, fee-schedules and claim rules.
• Experience with benefits set-up and prior authorizations processes.
• Knowledge of Medicare Advantage operational and regulatory guidelines.
• Excellent organizational and communication skills; ability to communicate ideas in both technical and user-friendly language.
• Ability to manage priorities and execute tasks in a high-pressure environment.
• Strong analytical and critical thinking skills.
• Experience working in a team-oriented, collaborative environment.
• Computer literacy: MS Excel, MS Word and MS PowerPoint.

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

No Third Party Agencies or Submissions Will Be Accepted.   

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP   

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.