Configuration Specialist - Pricing

Centivo•Buffalo, NY

8d•Remote

About The Position

We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Summary of role: The Configuration Specialist Pricing role is responsible for the accurate and timely configuration and maintenance of provider contract and pricing configurations within Centivo’s core systems. This role involves interpreting contract terms, setting up fee schedules, and ensuring compliance with regulatory and organizational standards to support timely and accurate claims adjudication and provider payments. Key responsibilities include collaborating with the Network Contracting and Provider Relations team, configuring pricing mechanisms and fee schedules, coordinating with business units and vendors during client implementations, and ensuring system interfaces meet client and operational needs.

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 form others, including but not limited to reimbursement policy standards.
Strong people skills, establishing rapport and working well with others.

Nice To Haves

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.

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.
Provide technical support and training for other team members as needed.