Provider Contracting Specialist

State of Oklahoma•Oklahoma City, OK

1d•Onsite

About The Position

The Provider Contracting Specialist is responsible for managing provider contracts, maintaining provider relationships, and ensuring compliance with applicable regulations and policies. This role includes handling incoming and outgoing communications, maintaining accurate provider data, and supporting provider network management activities to ensure efficient and effective service delivery.

Requirements

Knowledge of provider contracting, health insurance operations, reimbursement methodologies, claims processes, regulatory requirements, and provider database maintenance.
Strong organizational, analytical, customer service, written and verbal communication, negotiation, and problem-solving skills.
Ability to manage multiple priorities, maintain accurate and confidential information, interpret contract provisions and policies, and build effective relationships with providers and internal partners.
Ensures Accountability, by consistently meeting accuracy, quality, and timeliness standards.
Communicates Effectively, by providing clear, responsive, and professional communication.
Manages Complexity, by evaluating detailed contractual, regulatory, reimbursement, and provider-related information to resolve issues and support effective network operations.
A bachelor’s degree and 2 years of experience in health insurance benefit administration or health care industry provider contracting OR An equivalent combination of education and experience.
Must be willing to complete all job-related travel associated with this position.
Being present at the office is an essential function of this position.

Nice To Haves

Knowledge of Medicare guidelines policies and procedures.
Knowledge of provider licensing, certification, contractual issues, reimbursement, procedural coding, benefit coverage and liability requirements.
Knowledge of provider database maintenance, plan provisions, agency policies, provider types, credentials management, coding and reimbursement methods, claims payment process, and contract provisions/terminology.
Strong organizational skills.
Knowledge of large group network management and provider services to include provider enrollment and contracting, verbal and written communication skills, customer services and experience providing phone coverage, provider recruitment, training, response to member and provider inquiries, use of network database applications.
Requires a detailed understanding of insurance plan provisions, terms, policies, provider types, credentials management, coding and reimbursement methods, claims payment processes, contract provisions and terminology.
Knowledge of and ability to use Microsoft Office Applications.

Responsibilities

Ensure accurate and timely management of provider contracts, including pricing NSA claims, negotiating NSA requests, and responding to independent dispute resolutions.
Foster strong working relationships with providers through effective communication, timely response to inquiries, and proactive resolution of issues.
Adhere to HIPAA regulations, OMES policies, and other relevant statutes by protecting the privacy and confidentiality of program participants' information.
Enter and review provider demographics accurately and timely, ensuring an accuracy rate of 97% or better based on audits.
Handle incoming and outgoing calls, emails, and provider retention tasks while maintaining a customer service quality audit score of 85% or better.
Other duties as assigned.