Claims Management - PK- Provider Network Specialist

Our goals are to provide excellent service, utilize advanced technology, and proficiently deliver results. To accomplish these goals, we constantly seek individuals who look for ways to do things better. We are a company whose culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement.
 

Tabula Rasa HealthCare (TRHC) is a leader in providing patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize performance to improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. Medication risk management is TRHC’s lead offering, and its cloud-based software applications, including EireneRx® and MedWise™, provide solutions for a range of payers, providers and other healthcare organizations.

 

TRHC empowers our employees to provide excellent service, utilize advanced technology, and proficiently deliver results. Our 32Fundamentals are what we are and who we are.  Our culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement. As a part of our team, you will help us bring innovative service models to healthcare, improving patient outcomes.

PeakTPA provides services that optimize your organization’s financial management and fulfill regulatory requirements for health plan functions. Our expertise in health plan management, particularly in PACE, means you can focus on delivering high-quality care to your participants.

Summary: Under the supervision of the Provider Network Supervisor, the Provider Network Specialist is responsible for creating provider records in the claims processing system and linking records to the appropriate fee schedule. This position is also responsible for analyzing and interpreting provider contracts to ensure accurate reimbursement.

 

Essential Functions:

Creates provider and vendor records in claims processing system

Builds and maintains fee schedules based on submitted provider contracts

Assigns fee schedules to appropriate provider and vendor records

Effectively analyzes and interprets provider contracts

Manages pended claims that require additional contractual review

 

Additional Functions:

Assists with special projects, as requested

Communicates clearly and concisely, with sensitivity to the needs of others

Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees

Maintains courteous, helpful and professional behavior on the job

Establishes and maintains effective working relationships with co-workers

Ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards

Follows all Policies and Procedures and HIPAA regulations

Maintains a safe working environment

 

Supervisory Responsibility: None

 

Travel: Minimal travel, less than 10%, expected for this position

 

Knowledge, Skills and Abilities:

Educational requirements include a High School Diploma or equivalent. Three years of professional work experience in a Health Plan Management setting is preferred  

Knowledge of provider contracts, fee schedules and payment methodologies

Knowledge of medical terminology

Knowledge of medical claims processing   

Knowledge and experience using current computer technology, and a strong knowledge of Excel and Microsoft Word.   

Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels 

Skilled in data analysis and problem solving using defined methodologies

Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency 

Ability to work independently with minimal supervision

Ability to have superior attendance to fulfill all position functions

Ability to independently follow through on projects

Ability to communicate professionally, clearly and effectively, verbally and in writing

Ability to prioritize effectively

Ability to consistently multitask

 

Physical Demands & Requirements:

Communicate by way of the telephone with participants, customers, vendors and staff

Operate a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer

Remain stationary for extended periods of time

Occasionally exert up to 20 pounds of force to lift, carry, push, pull or move objects

Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy

Occasional reaching to retrieve shelved items

Occasional bending/stooping

 

Work Environment:

This job operates in a professional office environment, or home office environment, with a conversational noise level.  

No substantial exposure to adverse environmental conditions is expected.

Moderate pressure to meet scheduled appointments and deadlines

Potential for occasional verbal aggression by clients and vendors

The Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.

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