Provider Network Specialist

MedPro Group•Springfield, MA

6d•$23 - $25•Hybrid

About The Position

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace. Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market. The ideal person in this position will have experience working in the health insurance industry and be familiar with PPO Network operations and applying them to practical daily operations. The ideal candidate should also be familiar with provider contracting, provider relations, provider billing, coding and appeals. In this role, you will…

Requirements

Associate’s degree in Health Administration, Business Administration, or an equivalent combination of education and work experience in related field.
Two to three years of experience working in health insurance industry with focus on medical provider contracting, relations, and/or medical provider billing and coding
Exemplary Customer service experience
Excellent skills in the following areas: verbal/written communication, attention to detail and be accountable and take ownership of all work, multi-tasking
Ability to work independently and as a member of the team
Ability to maintain composure and diplomacy in negotiations and when under pressure or challenged
Detailed orientated problem solver with excellent time management skills
Proficiency with MS Office products to include Outlook, Excel, and Word

Nice To Haves

Health insurance industry experience preferred.

Responsibilities

Research, respond (by phone and email) and track inquiries in a timely manner that come into the Provider Relations mailbox
Have the ability to reprice claims in LuminX system for all networks
Have the ability to add and maintain LuminX provider records for all school plans; Provider maintenance updates are part of the Provider Department’s Key Performance Metrics and are routinely monitored
Call providers to obtain updates for Tax ID numbers and W9 forms
Have the ability to work the LuminX mailbox within turnaround time standards so claims team can meet prompt pay claim requirements per State Law
Handle Electronic Data Interchange (EDI) claim rejections and work with PPO networks to get pricing and apply manual repricing as needed
Coordinate with cost-containment vendor on claim edits and audits, claim cancellations, and appeals
Handle Provider Appeals by researching and using analytical skills to evaluate facts and work with provider networks and vendors to resolve appeals. Maintain tracking spreadsheet to monitor number of appeals
Be able to research issues with and process provider returned checks
Participate in PPO Network and vendor quarterly oversight calls/meetings as needed
Have the ability to work on remote claim repricing when networks are beyond expected turnaround times
Research provider reimbursement inquiries related to provider agreements with clients and PPO networks using PPO network/vendor portals
Cross train on all provider network tasks within the department
Create and maintain process documentation for tasks performed by the Provider Network Team
Provide assistance to the Head of Provider & Network Management and the Provider Network Manager on ad hoc projects that support provider network and benefit the company as a whole
Perform other duties as assigned

Benefits

Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

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