Contract Configuration Specialist Lead

Regal Medical Group•Los Angeles, CA

64d

About The Position

Provides support in the ongoing maintenance and configuration of Regal Medical Group systems, including but not limited to the data entry of Contracting Database, Providers, Vendors, Fee schedules, Capitation Configuration. Performs system maintenance functions in a manner that is responsive to customer needs and support Regal initiatives.

Requirements

Ability to review and interpret contract language.
Experience with EZCap configuration and operation.
Industry experience and knowledge of Industry standard Fee schedules and timing of standard fee schedule updates.
Ability to understand system configuration implications on UM and Claims processes.
2 years of Claims experience preferred.
Excellent written and verbal communication skills.
Typing/Data entry skills and accuracy.
Proficient in the use of personal computers, including Crystal Reports, Access database and MS Office applications.
Internet access and browsing.

Nice To Haves

Medical group or IPA operations information systems management experience preferred.
Understanding of the Health care industry, benefits and eligibility processes preferred.
Appropriate industry experience and/or certification preferred.

Responsibilities

Adheres to Data integrity policies for all system configurations.
Responsible for the data entry of claims system support tables and may be required to perform specialized area data entry or general data maintenance for eligibility, providers, fee sets and benefits or any other areas that require ongoing.
Proficient in multiple areas of data management (fee sets, benefits, eligibility, contracts, provider set up, vendor).
Responsible for the accurate and timely completion of tasks assigned.
Performs random audits as required to support policies and procedures for data integrity.
Communicates with management and makes recommendations to improve processes.
Ensure all systems within their area of responsibility are reliable, responsive and support to the needs of the Regal Medical Group network.
Maintains a customer satisfaction focused, service mentality to strengthen and build relationships with Heritage Provider Network and other Regal Medical Group.
The provider adds report is run daily to identify if provider needs to be added to system.
The report must be sorted by Pend flags status and then received date.
Pending for Eligibility are priority and must be completed same day.
Receive date greater than 5 days from current date are priority must be completed same day.
Receive date less than 5 days from current date must be completed with 3 – 4 days.
Contracted TIN or Provider must be verified if provider is contracted via CDB access database.
If provider is not found, must flag provider with PC (Pending Credentialing) flag.
If provider is found under a different TIN must via email contact assigned Network Manager to confirm if provider is part of the contracted group/TIN and/or TIN changed.
If provider is found all criteria’s match, add provider and link Key ID to referral network(s).
Non Contracted TIN or Provider is validated if Provider or TIN not found as in the CDB database.
Provider must be loaded as non-contracted by applying our U&C standard rates.
Individual and Group NPI must be validated via NPI Registry.
Vendor Name must be validated via IRS website.
Facility with health plan reciprocity contract worked on a daily basis.
Reciprocity rates apply when facility and HPN have not contract. The facility will accept Health plan rates as payment.
Identify high volume non-contracted providers.
P:\Finance\hospital reciprocity rates worksheet if provider is listed.
5 - 7 facilities must be complete on daily day in all databases (LMG, GCMG, and RMG).
Attends administrative meetings as requested.
Provides training to other staff members in data management.
All other duties as directed by management.