Rates Configuration Specialist I

MedPOINT Management; Los Angeles (CA); On-site; USD 73,000 - 78,000; Full time

Job summary

MedPOINT Management seeks a Rates Configuration Specialist I to create, update and maintain provider dictionaries, vendor contracts and fee schedules, ensuring accurate setup for claims adjudication.

The role requires 2+ years in managed care rate configuration, EZ-CAP experience, and strong knowledge of ICD-9, CPT, HCPCS codes, and Medicare/Medi-Cal fee schedules; proficiency in MS Office, SQL and Crystal Reports is a plus.

Qualifications

• 2+ years of managed care or healthcare experience in rate configuration, terms and conditions, reimbursement, or claims auditing
• EZ-CAP experience required
• Strong understanding of ICD-9, CPT, HCPCS codes, Medicare and Medi-Cal fee schedules, RVUs, and ASA reimbursement
• Intermediate knowledge of medical terminology, with the ability to interpret contracts and summaries
• Proficiency with Microsoft Office Suite (Access, Word, Excel, PowerPoint, Outlook), Crystal Reports, and SQL
• Familiarity with basic Internet terminology and functionality

Responsibilities

• Learn and understand the end-to-end process for creating and maintaining provider dictionaries and fee schedules based on contract terms.
• Assign appropriate fee schedules to providers, including exceptions, in accordance with provider contract terms.
• Build and maintain logs tracking fee schedule and fee set assignment implementations.
• Audit EZ-CAP provider and vendor configurations, including fee schedules and fee set assignments.
• Communicate errors to MPM stakeholders and elevate EZ-CAP issues to department leadership and HIT teams.
• Assist the PNO Network Management team and Field Representatives with provider concerns.
• Coordinate with the Benefits and Claims teams to resolve provider configuration and reimbursement issues.
• Support per diem reporting, analysis, and related requests.
• Understand and follow Employee Handbook policies and procedures.
• Ensure HIPAA compliance at all times.
• Perform other duties and assignments as needed.

Skills

Rate configuration

Healthcare experience

Contract interpretation

Data analysis

Attention to detail

Customer service

Time management

Tools

SQL

Crystal Reports

MS Access

Excel

PowerPoint

Outlook

Job description

Under the general direction of the Lead, Rates Configuration Specialist, the Rates Configuration Specialist I is responsible for creating, updating and maintaining provider dictionaries, vendor contracts, fee schedules, reading and interpreting contracts and/or contract summaries, and assigning fee schedules to providers. Should also be able to create reports relating to Vendor Contracts, Fee Schedules or Dictionaries for audit needs and ongoing rate evaluation, monitoring and testing. Responsible for the accuracy of system set up for adjudication of claims based on contractual language and rate terms.

Duties and Responsibilities:

• Learn and understand the end-to-end process for creating and maintaining provider dictionaries and fee schedules based on contract terms.
• Assign appropriate fee schedules to providers, including exceptions, in accordance with provider contract terms.
• Build and maintain logs tracking fee schedule and fee set assignment implementations.
• Audit EZ-CAP provider and vendor configurations, including fee schedules and fee set assignments.
• Communicate errors to MPM stakeholders and elevate EZ-CAP issues to department leadership and HIT teams.
• Assist the PNO Network Management team and Field Representatives with provider concerns.
• Coordinate with the Benefits and Claims teams to resolve provider configuration and reimbursement issues.
• Support per diem reporting, analysis, and related requests.
• Understand and follow Employee Handbook policies and procedures.
• Ensure HIPAA compliance at all times.
• Perform other duties and assignments as needed.
• 2+ years of managed care or healthcare experience in rate configuration, terms and conditions, reimbursement, or claims auditing
• EZ-CAP experience required
• Strong understanding of ICD-9, CPT, HCPCS codes, Medicare and Medi-Cal fee schedules, RVUs, and ASA reimbursement
• Intermediate knowledge of medical terminology, with the ability to interpret contracts and summaries
• Proficiency with Microsoft Office Suite (Access, Word, Excel, PowerPoint, Outlook), Crystal Reports, and SQL
• Familiarity with basic Internet terminology and functionality

Skills and Abilities:

• Strong customer service skills with the ability to resolve complaints and concerns
• Excellent attention to detail and accurate communication/documentation
• Proven analytical and critical thinking abilities
• Effective multi-tasking, time management, and ability to meet deadlines
• Ability to work positively in a dynamic, fast-paced team environment and achieve objectives

Salary Range:

• $72,500 – $77,500 annually