Provider Contract Specialist

Work model: start with on-site until training is completed and candidate is ready for remote work. The team will evaluate weekly and will switch the candidate to our hybrid model as soon as the candidate is read. The client current hybrid model is 3-day on site 2 day remote.

Start date: Immediately

Position Summary:

The Provider Contract Specialist is tasked with the responsibility of efficiently ensuring provider contract terms and rates are propagated through all client systems. This includes ensuring synchronization and validation of these terms into the Contracts Authorizations and Claims databases. This role facilitates a seamless implementation process for providers and conducting thorough audits of rates within the databases to guarantee accuracy.

Acting as a vital liaison between departments the Provider Contract Specialist closely collaborates with the Associate Vice President (AVP) of Claims and the Vice President (VP) of Authorizations (Operations) as well as their teams.

Additionally this role involves coordinating with third-party software vendors to articulate requirements develop and test solutions for the effective implementation of business processes.

Qualifications expertise and preferred skills:

• Expert knowledge of Microsoft Excel including expertise with formulas macros V-Lookup and H-Lookup data manipulation and advanced formulas.
• Detail oriented but with ability to see the big picture at the same time.
• Ability to effectively work on multiple projects at the same time while meeting deadlines
• Ability to anticipate recognize and resolve issues before they become problems.
• Ability to work well with multiple disciplines
• Following training and provided guidance the candidate should have the ability to resolve complex claims/authorization issues with minimal supervision

Specific Duty and responsibilities:

• Serve as the primary finance liaison with the internal compliance department ensuring that contract information meets the meets the specific data and workflow requirements for the claims adjudication system
• Collaborate with external provider networks to obtain essential data elements and formats ensuring the receipt of all necessary information for accurate and timely claims processing. This role is critical in verifying that payment information is correctly captured and integrated which is vital for the efficient and effective adjudication of claims. By maintaining clear communication and coordination with external partners this individual ensures that all relevant data is available reducing errors and delays in the payment process.
• Work with the IT department to obtain develop and integrate automated files from contracts for blanket provider amendments such as minimum wage adjustments. This role is crucial for ensuring that all amendments are accurately reflected in the system thereby maintaining compliance and consistency in provider payments. By collaborating closely with IT this individual ensures that automated updates are seamless and error-free facilitating the smooth and efficient processing of provider amendments.
• Obtain contracts and contract amendments from Compliance as they are executed. Ensure that all information is entered timely to ensure no delays in payment.
• Perform and oversee regular audits of the claims system to ensure that rates are entered accurately taking ownership of this critical compliance and regulatory process. This role is vital for maintaining the integrity and accuracy of the claims adjudication system ensuring that all rates comply with regulatory standards. By conducting thorough and regular audits this individual ensures that any discrepancies are promptly identified and corrected thereby upholding the organizations commitment to compliance and accurate financial processing.
• Download and review monthly CMS precluded provider list. Design automated process to compare to Intellisoft and MCO. Notify SVP Regulatory Affairs VP Operations SVP MLTC so that contract can be terminated authorizations changed and clinical staff notified
• Terminate precluded providers in PPI.
• Perform same function for NY State excluded providers as for CMS.
• Add non-contracted providers to Case Trakker and PPI daily.
• Maintains tracking system of all data loaded into Intellisoft and MCO
• Closely collaborate with the Associate Vice President (AVP) of Claims and the Vice President (VP) of Authorizations (Operations) taking ownership of key operational processes. This role is essential for ensuring seamless coordination and communication between departments which is critical for maintaining compliance and operational efficiency. By working directly with senior leadership this individual ensures that strategies and decisions are aligned with organizational goals and regulatory requirements thereby enhancing overall performance and compliance.
• Coordinate with third-party software vendors to articulate requirements develop and test solutions for the effective implementation of business processes. This role is essential for ensuring that the software solutions meet the organizations needs and support critical business functions. By clearly communicating requirements and actively participating in the development and testing phases this individual ensures that the final solutions are robust efficient and aligned with business objectives thereby enhancing overall operational effectiveness.

The client Customer Service Skills:

• Demonstrates teamwork promotes harmonious relationships and positive attitudes among residents patients members clients visitors and co-workers. Utilizes established channels of communication.
• Anticipates our members needs and offers to help our members visitors and co-workers to Live Forward.
• Listens asks appropriate questions and repeats the question back to the residents patients members clients visitors and co-workers to ensure understanding.
• Smiles makes direct eye contact while conversing and speaks with a respectful tone and positive body language.
• Demonstrates compassion helpfulness empathy sensitivity and respect when caring for residents patients clients and members needs and working with co-workers and/or visitors.
• Remains calm in difficult stressful situations and demonstrates patience when dealing with residents patients members clients visitors and co-workers members visitors or co-workers.
• Immediately acknowledges the presence of a resident patient member client visitor and/ co-worker and asks How I can help you Always smiles and makes direct eye contact with the person he/she is speaking to.
• Responds to complaints in a prompt manner and deploys effective service recovery strategies to resolve the issue. If unable to resolve the issue finds the person who can.
• Presents a professional image in dress demeanor and language. Wears identification badge at all times
• Adheres to the client telephone and written/email communication etiquette and practices proper elevator etiquette by being mindful of residents patients members clients visitors and co-workers.
• Demonstrates openness to suggestions and responsiveness to constructive feedback by making appropriate changes in behavior.
• Displays willingness to learn new skills to enhance the service provided within the client continuum.
• Upholds the privacy and confidentiality of our residents patients clients and members and prospective members by complying to HIPAA policy and procedures

ATD Technology LLC is a certified minority woman owned business that creates opportunities to match qualified individuals with client programs while meeting all parties financial and technical goals. ATD is a full service provider with offerings in Contract Permanent and Temp-to-Perm staffing solutions. We serve Fortune 1000 mid cap and small cap companies in the Commercial Public and Government sectors.