The Configuration Specialist - Pricing is responsible for accurately configuring and maintaining provider contract and pricing data within Centivo’s core systems. This role ensures compliance with regulatory and organizational standards, supports claims adjudication, and collaborates with internal teams and vendors during client implementations.
Responsibilities
- Ability to read and interpret new and existing physician, facility and ancillary contracts.
- Perform manual pricing based on accurate interpretation of contract language.
- Configure and maintain provider contracts in the health plan’s database systems.
- Interpret and apply contract terms, fee schedules, and reimbursement methodologies.
- Skilled in interpreting and implementing both new and existing contract pricing configurations within the Centivo pricing platform, ensuring comprehensive client and claims administration aligned with product design and functionality, and conducting necessary test validations.
- Identify contracts that are incompatible with Centivo’s pricing platform and collaborate with external pricing vendors to ensure accurate integration of these contracts into their systems as needed.
- Collaborate with the Network Management, Provider Relations and Claims team when contracts are built or corrected to ensure updates are made in all systems pertaining to contracted providers.
- When contract accuracy is in question, analyze claim impact reports to determine if claims are priced correctly.
- Complete claim adjustments based on provider disputes, requests from internal departments and as determined by analyzing Claim Impact reports.
- Complete configuration changes as identified, run, and evaluate claim adjustment reports within Centivo’s claim platform and supporting systems.
- Perform unit and/or end user testing for new configuration, programming enhancements, new provider contracts, and software changes as necessary that affect claims adjudication rules.
- Participate in special projects as needed and function as a liaison with specified user areas to define business requirements and processes for project deployment.
Requirements
- Demonstrated ability to identify when platform limitations or capabilities require a contract to be sent to an external pricing vendor.
- Ability to perform contract reviews to determine accuracy in configuration and correct as needed.
- Ability to analyze claims for pricing accuracy against contract requirements.
- Exemplary customer service skills demonstrated by researching and resolving issues that are configuration related in a timely and accurate manner.
- Possess excellent analytical and problem-solving skills.
- Ability to work independently and as part of a team.
- Ability to multi-task and apply critical thinking skills.
- Strong attention to detail and accuracy.
- Enjoy working in a fast-paced environment managing multiple issues with pressure of production schedules and deadlines.
- Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others, including but not limited to reimbursement policy standards.
- Strong people skills, establishing rapport and working well with others.
Preferred Qualifications
- 3 years of experience in provider contract configuration, health plan claims process or a similar role preferred.
- In-depth knowledge of all claim components that influence pricing, including the requirements for UB and HCFA forms.
- Knowledge and experience in coding with Current Procedural Terminology (CPT), Healthcare Common Procedure Code System (HCPCS), International Classification of Diseases 10th Revision (ICD-10), Revenue and Diagnosis Related Groups (DRG), Current Dental Terminology (CDT), other relevant medical and industry-standard codes.
- Proficient in professional and institutional claims adjudication.
- Knowledge in health insurance benefit administration within a self-funded plan.
- The ideal candidate will have HealthRulesPayer (HRP) and HealthEdge Source (Source) experience.
- Knowledge of TPA and self-funding processes and system contract configuration is preferred.
- Advanced proficiency in Microsoft Office applications.
Technical Stack
HealthRulesPayer (HRP), HealthEdge Source (Source), Microsoft Office
Work Arrangement
Remote (Global)
