Provider & Contract Configuration Specialist

Capital Health Plan • Tallahassee, FL

17d • Onsite

About The Position

We are seeking a Provider & Contract Configuration Specialist to support the accurate configuration, testing, and maintenance of provider contracts and fee schedules within Capital Health Plan's core operating systems. This role plays a critical part in ensuring accurate claims adjudication through precise system set‑up, testing, implementation, and documentation of provider contracts, code sets, and reimbursement methodologies. The Provider & Contract Configuration Specialist works closely with Claims, IT, Contract Administration, and Medical Leadership to troubleshoot pended claims, resolve provider disputes, and support system enhancements. This position also participates in testing efforts, analytical projects, and cross‑functional initiatives to improve operational accuracy, efficiency, and compliance.

Requirements

• Bachelor's degree from an accredited four-year college or university, or equivalent education and experience
• Minimum of two years of related experience in provider configuration, contract administration, claims adjudication, or healthcare operations preferred
• Strong understanding of provider contracts, fee schedules, and claims adjudication processes
• Experience configuring effective dates, fee schedules, code sets, and contract terms within healthcare systems
• Ability to analyze and resolve pended claims and provider appeals with a results-oriented approach
• Strong analytical, problem-solving, and documentation skills
• Ability to communicate clearly and effectively with internal stakeholders across departments
• Proficiency with Microsoft Office applications, including Word, Excel, and Outlook

Nice To Haves

• Experience working with claims or contract configuration systems (e.g., QNXT or similar payer platforms)
• Coding certification through AAPC or AHIMA
• Knowledge of reimbursement methodologies such as relative value units, case rates, DRGs, per diems, or capitated arrangements
• Experience testing system changes or add-on coding software in collaboration with IT and Claims teams
• Strong understanding of CPT, ICD, revenue codes, and medical terminology
• Experience supporting contract negotiators by assessing administrative complexity of contract terms

Responsibilities

• Accurate configuration, testing, and maintenance of provider contracts and fee schedules within core operating systems.
• Ensuring accurate claims adjudication through precise system set-up, testing, implementation, and documentation of provider contracts, code sets, and reimbursement methodologies.
• Troubleshooting pended claims and resolving provider disputes.
• Supporting system enhancements.
• Participating in testing efforts, analytical projects, and cross-functional initiatives to improve operational accuracy, efficiency, and compliance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees