Sr. Contract Configuration Specialist

Job Description

The Senior Contract 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. Responsible for creating, updating and maintaining capitation tables for capitated providers. Should also be able to create reports relating to Vendor Contracts, Fee Schedules or Dictionaries for audit or other purposes.

Responsibilities

• 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.
  
  

Qualifications

Minimum Education: Associate degree or 4 years degree preferred.

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.

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.