Provider Network Specialist

Qualifications:

  • Two to three years of experience working in health insurance industry with focus on medical provider contracting, relations, and/or medical provider billing and coding
  • Exemplary Customer service experience
  • Excellent skills in the following areas: verbal/written communication, attention to detail and be accountable and take ownership of all work, multi-tasking
  • Ability to work independently and as a member of the team
  • Ability to maintain composure and diplomacy in negotiations and when under pressure or challenged
  • Detailed orientated problem solver with excellent time management skills
  • Proficiency with MS Office products to include Outlook, Excel, and Word
  • Associate’s degree in Health Administration, Business Administration, or an equivalent combination of education and work experience in related field.
  • Health insurance industry experience preferred.

General responsibilities and duties include:

  • Manage, research, respond (by phone and email) and track inquiries in a timely manner that come into the Provider Relations mailbox
  • Ability to reprice claims in LuminX system for all networks
  • Ability to add and maintain LuminX provider records for all schools and Employer groups; Provider maintenance updates are subject to CHP TRACK program guidelines*
  • Call providers to obtain updates for Tax ID numbers and W9 forms
  • Ability to work LuminX mailbox within turnaround time standards so claims team can meet prompt pay claim requirements per State Law
  • Handle Electronic Data Interchange (EDI) claim rejections and work with PPO networks to get pricing and apply manual repricing as needed
  • Coordinate with cost-containment vendor on claim edits and audits, claim cancellations, and appeals
  • Handle Provider Appeals by researching and using analytical skills to evaluate facts and work with provider networks and vendors to resolve appeals. Maintain tracking spreadsheet to monitor number of appeals
  • Ability to research issues with and process provider returned checks  
  • Manage 1099 reporting and yearly First B notices with submission of reports to the Internal Revenue Services (IRS) and Department of Revenue (DOR)
  • Manage and negotiate direct provider agreements, single case agreements and fee schedules on behalf of clients
  • Practice independent judgement and courses of action relative to negotiating provider rates, composing appropriate agreement language and terms, resolving escalated provider issues, and analytical reporting
  • Program fee schedules in LuminX claims processing system
  • Work with Plan Building Dept. to determine if negotiated payment structure can be supported in LuminX
  • Coordinate implementation of executed agreements by notifying all impacted departments.
  • Add new PPO codes to LuminX system
  • Notify Preferred Provider Organization (PPO) networks of new groups and setup changes
  • Participate in PPO Network and vendor quarterly oversight calls/meetings
  • Remote claim repricing when networks are beyond expected turnaround times
  • Research provider reimbursement inquiries related to provider agreements with clients and PPO networks using PPO network/vendor portals
  • Cross train on all provider network tasks within the department
  • Create and maintain process documentation for tasks performed by the Provider Network Team
  • Provide assistance to the Provider Network Manager on ad hoc projects that support provider network and benefit the company as a whole
  • Provide back-up to Pharmacy Dept. as needed:    
    • Answer incoming phone calls routed to pharmacy line and assist members with pharmacy overrides and prior authorizations
    • Submit pharmacy overrides via PBM portal and/or service contact
    • Other duties as assigned

 

TRACK Guidelines (subject to change):

  • Minimum: Net Points per Day Requirement 300
  • Goal: Net Points Per Day 350 – 374
  • Stretch: Net points per Day 375 and above
  • Accuracy: 98% or above regardless of overall net point value

 

Reporting to:  Provider Network Manager 

 

Please send your resume and completed application to CHP Human Resources at:

Mail: Consolidated Health Plans, Human Resources, 2077 Roosevelt Avenue, Springfield, MA 01104-3503

Fax: (413) 452-5329 Attn. Human Resources

Email: human_resources@consolidatedhealthplan.com

Phone: (413) 733-4540 ext. 258

 

Employment Application

Download Employment Application

 

For more information contact us at human_resources@consolidatedhealthplan.com or call us at (413) 733-4540 ext. 258